NPIMap

Organization Active NPI

Lakeland Immediate Care Center

Doing business as Niles Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Niles, MI
National Provider Identifier
1760802912
Registry record updated Sep 4, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LAKELAND IMMEDIATE CARE CENTER
Doing business as
Niles Community Health Center
Practice address
1951 Oak St
Niles, MI 49120-3738
Phone
(269) 262-4749
Fax
(269) 262-4739
NPI assigned
Apr 25, 2014
Last updated
Sep 4, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
LAKELAND IMMEDIATE CARE CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 4, 2025

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

Authorized official

Name
Joseph Gavan
Title
Executive Director
Phone
(269) 445-3874

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X
Federally Qualified Health Center (FQHC) 261QF0400X MI Primary

Addresses

Primary practice location

1951 Oak St
Niles, MI 49120-3738

Mailing address

1951 Oak St
Niles, MI 49120-3738
Phone (269) 262-4749

Other names 1

  • Niles Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040524000042 MI Part B Supplier - Clinic/Group Practice 2264423771 Receives reassigned benefits from 38 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Cassopolis, MI; Niles, MI
O20140407000688 MI Part A Provider - Federally Qualified Health Center (FQHC) 2264423771 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Niles, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760802912. Details of each certification follow.

Federally qualified health center certification: CCN 231023

Legal name
LAKELAND IMMEDIATE CARE CENTER
Doing business as
NILES COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 20, 2014
Last certification
May 20, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 7, 1993 in MI
Enrollment address
1951 Oak St
Niles, MI 49120-3738

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Part of
Lakeland Immediate Center

Locations

1951 Oak St
Niles, MI 49120
Phone (269) 262-4749

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tammy M Howard Individual W-2 Managing EmployeeChief Operations Officer Mar 3, 2014 100%
Patricia Patano Individual Corporate OfficerBoard Member Dec 6, 2019 100%
Marcella Taylor Individual Corporate OfficerBoard Member Feb 28, 2020 100%
Mary G Middleton Individual Corporate Director Jul 1, 1999 100%
Lakeland Immediate Care Center Organization, Niles, MI 5% Or Greater Direct Ownership Interest Feb 24, 2014 100%
Tracy D Hertsel Individual Corporate OfficerBoard Member Jun 1, 2005 100%
Dwaine Warren Individual Corporate OfficerBoard Member Sep 27, 2013 100%
Marsha Ellis Individual Corporate OfficerBoard Member Jan 1, 2013 100%
Adrienne Glover Individual Corporate OfficerBoard Member May 1, 2002 100%
Neil R See Individual Corporate OfficerBoard Member Jan 1, 2020 100%
Joseph Gavan Individual Corporate DirectorCeo Mar 18, 2024 100%
Ray Cruse Individual Corporate OfficerBoard Member Jul 1, 2015 100%
Leon Gilliam Individual Corporate OfficerBoard Member Sep 1, 2008 100%
Dolores McNeary Individual Corporate OfficerBoard Member Dec 1, 2014 100%
George Brossman Individual Corporate OfficerBoard Member Feb 1, 2005 100%
Joyce Bailey Individual Corporate OfficerBoard Member Dec 6, 2019 100%
Lisa Green Individual Corporate OfficerBoard Member Feb 25, 2022 100%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 15

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.

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1398384000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1756944000000",
    "number": "1760802912",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1951 OAK ST",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491203738",
            "telephone_number": "269-262-4749",
            "fax_number": "269-262-4739"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1951 OAK ST",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491203738",
            "telephone_number": "269-262-4749",
            "fax_number": "269-262-4739"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKELAND IMMEDIATE CARE CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LAKELAND IMMEDIATE CARE CENTER",
        "enumeration_date": "2014-04-25",
        "last_updated": "2025-09-04",
        "certification_date": "2025-09-04",
        "status": "A",
        "authorized_official_last_name": "GAVAN",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "269-445-3874"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MI",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Niles Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Niles, MI

Sources for this page

Verify at the official NPI Registry.