Provider Demographics
NPI:1700916335
Name:ST JOHNS HEALTH CARE PC
Entity type:Organization
Organization Name:ST JOHNS HEALTH CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:231-845-7922
Mailing Address - Street 1:609 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1503
Mailing Address - Country:US
Mailing Address - Phone:231-845-7922
Mailing Address - Fax:231-843-8491
Practice Address - Street 1:609 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1503
Practice Address - Country:US
Practice Address - Phone:231-845-7922
Practice Address - Fax:231-843-8491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI154625029Medicaid