NPIMap

Organization Active NPI

Traverse Health Clinic and Coalition

Doing business as Mobile Medical Van

  • Federally Qualified Health Center (FQHC)
  • Traverse City, MI
National Provider Identifier
1831866821
Registry record updated Jul 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
TRAVERSE HEALTH CLINIC AND COALITION
Doing business as
Mobile Medical Van
Practice address
1719 S Garfield Ave
Traverse City, MI 49686-4337
Phone
(231) 935-0799
Fax
(231) 935-0962
NPI assigned
Aug 26, 2021
Last updated
Jul 12, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
TRAVERSE HEALTH CLINIC AND COALITIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 12, 2023

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

Authorized official

Name
Casey Kandow
Title
Ceo
Phone
(231) 935-0799

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Non-emergency Medical Transport (VAN) 343900000X

Addresses

Primary practice location

1719 S Garfield Ave
Traverse City, MI 49686-4337

Mailing address

1719 S Garfield Ave
Traverse City, MI 49686-4337
Phone (231) 935-0799

Other names 2

  • Mobile Medical Van Doing business as
  • Traverse Health Clinic and Coalition Mobile Van #1 Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160811001634 MI Part A Provider - Federally Qualified Health Center (FQHC) 0547407181 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Traverse City, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1831866821. Details of each certification follow.

Federally qualified health center certification: CCN 231097

Legal name
TRAVERSE HEALTH CLINIC AND COALITION
Doing business as
TRAVERSE HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 10, 2016
Last certification
Aug 10, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 22, 2007 in MI
Enrollment address
1719 S Garfield Ave
Traverse City, MI 49686-4337

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
Traverse Health Clinic and Coalition

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Catherine F Allchin Individual Corporate DirectorBoard Secretary Sep 11, 2015
Traverse Health Clinic and Coalition Organization, Traverse City, MI Non-profit Operational/Managerial Control Sep 11, 2015
Heather D Dykstra Individual Corporate DirectorBoard Chair Sep 11, 2015
Karen a Bartone Individual Corporate DirectorConsumer Board Member Sep 11, 2015
Lyndsay Douglass Individual Corporate Director Sep 11, 2015
Natasha Martin Individual W-2 Managing Employee Sep 11, 2015
Amanda Hays Individual Corporate Director Sep 17, 2018
Jeffrey Rademacher Individual Corporate Director May 1, 2019
Raymond Otto Bohrer Individual Corporate DirectorBoard Vice Chair Sep 11, 2015
Deborah L Debruyn Individual Corporate DirectorConsumer Board Member Sep 11, 2015
Arlene J Brennan Individual Corporate DirectorExecutive Director Sep 11, 2015
W-2 Managing EmployeeExecutive Director Sep 11, 2015
Gary W Mateer Individual Corporate DirectorConsumer Board Member Sep 11, 2015
Edward B Carlson Individual Corporate DirectorBoard Treasurer Sep 11, 2015
Scott Gray Individual Corporate DirectorBoard Member Aug 1, 2017

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 11

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": "1629936000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1689120000000",
    "number": "1831866821",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1719 S GARFIELD AVE",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496864337",
            "telephone_number": "231-935-0799",
            "fax_number": "231-935-0962"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1719 S GARFIELD AVE",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496864337",
            "telephone_number": "231-935-0799",
            "fax_number": "231-935-0962"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRAVERSE HEALTH CLINIC AND COALITION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "TRAVERSE HEALTH CLINIC AND COALITION",
        "enumeration_date": "2021-08-26",
        "last_updated": "2023-07-12",
        "certification_date": "2023-07-12",
        "status": "A",
        "authorized_official_last_name": "KANDOW",
        "authorized_official_first_name": "CASEY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "231-935-0799"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "343900000X",
            "taxonomy_group": "",
            "desc": "Non-emergency Medical Transport (VAN)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mobile Medical Van",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Traverse Health Clinic and Coalition Mobile Van #1",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Traverse City, MI

Sources for this page

Verify at the official NPI Registry.