Provider Demographics
NPI:1174724454
Name:HEALTHY IMAGE SKIN AND BODY CLINIC PLLC
Entity type:Organization
Organization Name:HEALTHY IMAGE SKIN AND BODY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MACAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-345-3150
Mailing Address - Street 1:611 COURT ST
Mailing Address - Street 2:PO BOX 428
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-0428
Mailing Address - Country:US
Mailing Address - Phone:989-516-4317
Mailing Address - Fax:989-345-5803
Practice Address - Street 1:2492 I-75
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661
Practice Address - Country:US
Practice Address - Phone:989-345-3150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center