Crystal Lake Clinic P.c.

NPI #1417902057 in Interlochen, Michigan

Provider Information

NPI Number: 1417902057
Entity Type: Organization
Organization Name: Crystal Lake Clinic P.c.
Primary Specialty: Family Medicine
Enumeration Date: May 23, 2006
Last Updated: Feb 14, 2011

Practice Location

Address: 1975 STIRLING DR
City: Interlochen
State: Michigan
ZIP Code: 49643-9264
Phone: (231) 275-7965

Authorized Official

Name: RICHARD C NIELSEN, M.D.
Title: PRESIDENT
Phone: (231) 882-9661

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Pediatrics	208000000X
Family Medicine	207Q00000X	Primary

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