Provider Demographics
NPI:1700915709
Name:LUCE-MACKINAC HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:LUCE-MACKINAC HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-293-5107
Mailing Address - Street 1:14150 HAMILTON LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868
Mailing Address - Country:US
Mailing Address - Phone:906-293-5107
Mailing Address - Fax:
Practice Address - Street 1:14150 HAMILTON LAKE ROAD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868
Practice Address - Country:US
Practice Address - Phone:906-293-5107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2823509Medicaid
MI231545Medicare ID - Type Unspecified