NPIMap

Organization Active NPI

Crystal Lake Clinic, PC

  • Family Medicine Physician
  • Manton, MI
National Provider Identifier
1306190475
Registry record updated Oct 29, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CRYSTAL LAKE CLINIC, PC
Practice address
115 E 7TH St
Manton, MI 49663-9429
Phone
(231) 824-4100
Fax
(231) 824-4108
NPI assigned
Oct 29, 2012
Last updated
Oct 29, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 29, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Richard C Nielsen, MDNPI 1831113273
Title
President
Phone
(231) 882-9661

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

115 E 7TH St
Manton, MI 49663-9429

Mailing address

6227 Frankfort Hwy
Benzonia, MI 49616-8632
Phone (231) 882-9661

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040802000634 MI Part B Supplier - Clinic/Group Practice 0648259010 Receives reassigned benefits from 39 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Traverse City, MI; Suttons Bay, MI; Manton, MI; Manistee, MI; Interlochen, MI; Frankfort, MI; Elk Rapids, MI; Bear Lake, MI…

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2049142Crystal Lake Clinic P C115 E 7TH Street, Manton, MI 49663Certificate of waiverOct 30, 2026

National Provider Directory

National Provider Directory
Tax ID family
Crystal Lake Clinic PC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1351468800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1351468800000",
    "number": "1306190475",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6227 FRANKFORT HWY",
            "city": "BENZONIA",
            "state": "MI",
            "postal_code": "496168632",
            "telephone_number": "231-882-9661",
            "fax_number": "231-882-9616"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 E 7TH ST",
            "city": "MANTON",
            "state": "MI",
            "postal_code": "496639429",
            "telephone_number": "231-824-4100",
            "fax_number": "231-824-4108"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRYSTAL LAKE CLINIC, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-29",
        "last_updated": "2012-10-29",
        "status": "A",
        "authorized_official_last_name": "NIELSEN",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "231-882-9661",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Manton, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.