| Contacts | Primary Contact | Update | Profile Change Request | Chavez, Rafael John
Pharmacy Director
Center for Family Health
5177485400 | Chavez, Rafael John
Pharmacy Director
Center for Family Health
5177485400-1010 | 3/24/2025 8:16 AM |
| Contacts | Primary Contact | Update | PC Change Request | Darmofal, Gary
Pharmacy manager
Center for Family Health
5177485400 | Chavez, Rafael John
Pharmacy Director
Center for Family Health
5177485400 | 2/12/2025 6:39 AM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2024 1:32:44 PM | 2/11/2025 3:57:25 PM | 2/11/2025 3:57 PM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2023 10:03:44 AM | 2/9/2024 1:32:44 PM | 2/9/2024 1:32 PM |
| Contacts | Authorizing Official | Update | Group Change Request | BENEDETTO, SARA
CEO
Center for Family Health
5177485500 | Wypyski, Bill
CEO
Center for Family Health
5717485500 | 9/1/2023 5:09 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/13/2023 10:03 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1497825939 | 2/13/2023 10:03 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MI | 2/13/2023 10:03 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/13/2023 10:03 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1306137161 | 2/13/2023 10:03 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MI | 2/13/2023 10:03 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1306137161 | 2/13/2023 10:03 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 2/13/2023 10:03 AM |
| Contacts | Primary Contact | Update | Recertification | Pariseau, Julie
Pharmacy Manager
CH057030
5177485500-1010 | Darmofal, Gary
Pharmacy manager
Center for Family Health
5177485400 | 2/13/2023 10:03 AM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2022 10:56:44 AM | 2/13/2023 10:03:44 AM | 2/13/2023 10:03 AM |
| Contacts | Authorizing Official | Update | AO Change Request | KASER, MOLLY
CEO
Center for Family Health
5177485500 | BENEDETTO, SARA
CEO
Center for Family Health
5177485500 | 2/7/2023 3:15 PM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2021 2:02:14 PM | 1/31/2022 10:56:44 AM | 1/31/2022 10:56 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | MI | 2/4/2021 2:02 PM |
| Details | Last Recertification Date | Update | Recertification | 1/27/2020 10:49:42 AM | 2/4/2021 2:02:14 PM | 2/4/2021 2:02 PM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2019 8:34:04 AM | 1/27/2020 10:49:42 AM | 1/27/2020 10:49 AM |
| Details | Entity Name | Update | Change Request | CENTER FOR FAMILY HEALTH | Center for Family Health | 1/13/2020 12:28 PM |
| Details | Entity Name | Update | Change Request | CENTER FOR FAMILY HEALTH, INC. | CENTER FOR FAMILY HEALTH | 1/10/2020 12:55 PM |
| Details | Entity Subname | Update | Change Request | TEEN HEALTH CENTER AT PARKSIDE | CFH - Parkside Health Center | 1/10/2020 12:55 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1497825939 | 8/21/2019 2:13 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2018 11:18:55 AM | 2/4/2019 8:34:04 AM | 2/4/2019 8:34 AM |
| Details | Last Recertification Date | Update | Recertification | 1/26/2017 12:00:00 AM | 2/7/2018 11:18:55 AM | 2/7/2018 11:18 AM |
| Contacts | Authorizing Official | Update | | KASER, MOLLY
CEO
5177485500 | KASER, MOLLY
CEO
Center for Family Health
5177485500 | 2/5/2018 9:35 AM |
| Contacts | Primary Contact | Update | | Pariseau, Julie
Pharmacy Manager
5177485500-1010 | Pariseau, Julie
Pharmacy Manager
CH057030
5177485500-1010 | 9/29/2017 8:06 AM |
| Contacts | Authorizing Official | Insert | | | KASER, MOLLY
CEO
5177485500 | 7/10/2017 1:30 PM |
| Contacts | Primary Contact | Insert | | | Pariseau, Julie
Pharmacy Manager
5177485500-1010 | 3/8/2017 10:36 AM |
| Addresses | Main Address | Insert | | |
2400 4th St
Jackson, MI 49203-4573 | 1/26/2017 2:04 PM |
| Details | Last Recertification Date | Update | | 2/12/2016 12:00:00 AM | 1/26/2017 12:00:00 AM | 1/26/2017 2:04 PM |
| Details | Last Recertification Date | Update | | 1/28/2015 12:00:00 AM | 2/12/2016 12:00:00 AM | 2/12/2016 2:46 PM |
| Details | Last Recertification Date | Update | | 3/17/2014 12:00:00 AM | 1/28/2015 12:00:00 AM | 1/28/2015 2:11 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/17/2014 12:00:00 AM | 3/17/2014 6:58 AM |
| Addresses | Billing Address | Insert | | | CENTER FOR FAMILY HEALTH, INC.
2298 SPRINGPORT ROAD, SUITE B
JACKSON, MI 49202 | 2/6/2013 8:04 AM |
| Addresses | Billing Address | Update | | CENTER FOR FAMILY HEALTH, INC.
2298 SPRINGPORT ROAD, SUITE B
JACKSON, MI 49202 | CENTER FOR FAMILY HEALTH
505 N. Jackson Street
JACKSON, MI 49201 | 2/6/2013 8:04 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/6/2013 8:04 AM |
| Details | Last Recertification Date | Insert | | | | 8/22/2007 3:24 PM |
| Details | Grant Number | Insert | | | H80CS00772 | 8/22/2007 3:24 PM |
| Details | 340B ID | Insert | | | CH05703F | 8/22/2007 3:24 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 8/22/2007 3:24 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 8/22/2007 3:24 PM |
| Details | Medicare Provider Number | Insert | | | | 8/22/2007 3:24 PM |
| Details | Entity Name | Insert | | | CENTER FOR FAMILY HEALTH, INC. | 8/22/2007 3:24 PM |
| Details | Program Code | Insert | | | CH | 8/22/2007 3:24 PM |
| Details | Entity Subname | Insert | | | TEEN HEALTH CENTER AT PARKSIDE | 8/22/2007 3:24 PM |
| Dates | Participating Approval Date | Insert | | | 8/22/2007 12:00:00 AM | 8/22/2007 3:24 PM |
| Details | State | Insert | | | Active | 8/22/2007 3:24 PM |
| Dates | Registration Date | Insert | | | 8/21/2007 12:00:00 AM | 8/22/2007 3:24 PM |
| Dates | Signed By Date | Insert | | | 8/20/2007 12:00:00 AM | 8/22/2007 3:24 PM |
| Dates | Start Date | Insert | | | 10/1/2007 12:00:00 AM | 8/22/2007 3:24 PM |
| Terminations | Termination Comments | Insert | | | | 8/22/2007 3:24 PM |
| Terminations | Termination Date | Insert | | | | 8/22/2007 3:24 PM |
| Terminations | Termination Effective Date | Insert | | | | 8/22/2007 3:24 PM |
| Terminations | Termination Reason | Insert | | | | 8/22/2007 3:24 PM |