Provider Demographics
NPI:1902162746
Name:DELTA FAMILY CLINIC SOUTH PC
Entity Type:Organization
Organization Name:DELTA FAMILY CLINIC SOUTH PC
Other - Org Name:DELTA FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/ ADNIMISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:810-630-1152
Mailing Address - Street 1:6195 MILLER RD.
Mailing Address - Street 2:STE. A
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473
Mailing Address - Country:US
Mailing Address - Phone:810-630-1152
Mailing Address - Fax:810-630-9107
Practice Address - Street 1:901 N. EUCLID AVE.
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706
Practice Address - Country:US
Practice Address - Phone:989-671-9798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DELTA FAMILY CLINIC SOUTH P.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty