Provider Demographics
NPI:1194977314
Name:ADVENTURE CENTRE AT PRETTY LAKE
Entity type:Organization
Organization Name:ADVENTURE CENTRE AT PRETTY LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SZWAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:269-375-1664
Mailing Address - Street 1:9497 Q AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-8435
Mailing Address - Country:US
Mailing Address - Phone:269-375-1664
Mailing Address - Fax:
Practice Address - Street 1:9497 Q AVE
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-8435
Practice Address - Country:US
Practice Address - Phone:269-375-1664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QM0801X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health