Basic Information
| Provider Information | |||||||||
| NPI: | 1053635359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNOCK HOSPITAL BOARD OF TRUSTEES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENNOCK HOSPITAL LAKE ODESSA SAT LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 W GREEN ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490581710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699451212 | ||||||||
| FaxNumber: | 2699483117 | ||||||||
| Practice Location | |||||||||
| Address1: | 4294 LAUREL DR | ||||||||
| Address2: | |||||||||
| City: | LAKE ODESSA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488498430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699451212 | ||||||||
| FaxNumber: | 6166741698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | SALISBURY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2699451212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | MI | Y | Hospitals | General Acute Care Hospital |
No ID Information.