| Details | State | Update | | To Be Terminated | Terminated | 4/1/2024 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 3/1/2024 12:00:00 AM | 3/4/2024 10:00 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 3/4/2024 10:00 AM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2024 12:00:00 AM | 3/4/2024 10:00 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 3/1/2024 12:00:00 AM | 3/4/2024 10:00 AM |
| Terminations | Termination Reason | Update | Recertification | | Other | 3/4/2024 10:00 AM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2022 12:22:25 PM | 2/1/2023 8:17:33 AM | 2/1/2023 8:17 AM |
| Contacts | Primary Contact | Update | Change Request | Kujawa, Meredith
Chief Financial Officer
Lakleand Immediate Care Center
2694453874-137 | Klipowicz, Kevin
Pharmacy Director
Niles Community Health Center Pharmacy
2696658900 | 7/29/2022 7:22 AM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2021 1:52:37 PM | 2/8/2022 12:22:25 PM | 2/8/2022 12:22 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1760802912 | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1972913150 | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1811389570 | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 1982677548 | 2/5/2021 1:52 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1982677548 ( ) | | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760802912 | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1972913150 | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1811389570 | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1982677548 | 2/5/2021 1:52 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 2/5/2021 1:52 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2020 2:57:51 PM | 2/5/2021 1:52:37 PM | 2/5/2021 1:52 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2019 10:59:36 AM | 1/30/2020 2:57:51 PM | 1/30/2020 2:57 PM |
| Addresses | Main Address | Update | Change Request |
60 N Saint Joseph Ave
Niles, MI 49120-2296 |
1951 Oak St.
Niles, MI 49120-3738 | 12/16/2019 8:22 AM |
| Details | Last Recertification Date | Update | Recertification | 2/21/2018 11:12:05 AM | 2/7/2019 10:59:36 AM | 2/7/2019 10:59 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Neary, Meredith
Chief Financial Officer
Lakleand Immediate Care Center
2694453874-137 | Kujawa, Meredith
Chief Financial Officer
Lakleand Immediate Care Center
2694453874-137 | 2/1/2019 8:45 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2017 12:00:00 AM | 2/21/2018 11:12:05 AM | 2/21/2018 11:12 AM |
| Contacts | Authorizing Official | Update | | MIDDLETON, MARY GEEGAN
Chief Executive Officer
2694453874-109 | MIDDLETON, MARY GEEGAN
Chief Executive Officer
Cassopolis Family Clinic Network
2694453874-109 | 1/24/2018 1:34 PM |
| Contacts | Primary Contact | Update | | Neary, Meredith
Chief Financial Officer
2694453874-137 | Neary, Meredith
Chief Financial Officer
Lakleand Immediate Care Center
2694453874-137 | 1/9/2018 1:18 PM |
| Contacts | Authorizing Official | Update | | MIDDLETON, MARY GEEGAN
EXECUTIVE DIRECTOR
2696840259-1138 | MIDDLETON, MARY GEEGAN
Chief Executive Officer
2694453874-109 | 7/13/2017 1:57 PM |
| Contacts | Primary Contact | Update | | MIDDLETON, MARY GEEGAN
EXECUTIVE DIRECTOR
2696840259-1138 | Neary, Meredith
Chief Financial Officer
2694453874-137 | 3/16/2017 3:04 PM |
| Addresses | Main Address | Insert | | |
60 N Saint Joseph Ave
Niles, MI 49120-2296 | 2/13/2017 1:15 PM |
| Details | Last Recertification Date | Update | | 2/26/2016 12:00:00 AM | 2/13/2017 12:00:00 AM | 2/13/2017 1:15 PM |
| Details | Last Recertification Date | Update | | 2/10/2015 12:00:00 AM | 2/26/2016 12:00:00 AM | 2/26/2016 10:24 AM |
| Addresses | Billing Address | Insert | | | LAKELAND IMMEDIATE CARE CENTER
261 M-62
CASSOPOLIS, MI 49031-1034 | 1/20/2016 2:47 PM |
| Details | Last Recertification Date | Update | | 3/18/2014 12:00:00 AM | 2/10/2015 12:00:00 AM | 2/10/2015 3:54 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1982677548 | 3/18/2014 11:06 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/18/2014 12:00:00 AM | 3/18/2014 11:06 PM |
| Details | Entity Subname | Update | | CASSOPOLIS FAMILY CLINIC | Cass Family Clinic OB/GYN | 3/18/2014 11:06 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/7/2013 12:03 PM |
| Details | Comments Public | Insert | | | 3/28/12 - Changed email of AO and Contact from, mmiddleton@lakelandregional.org | 3/28/2012 3:48 PM |
| Contacts | Authorizing Official | Insert | | | MIDDLETON, MARY GEEGAN
EXECUTIVE DIRECTOR
2696840259-1138 | 6/30/2010 7:41 PM |
| Contacts | Primary Contact | Insert | | | MIDDLETON, MARY GEEGAN
EXECUTIVE DIRECTOR
2696840259-1138 | 6/30/2010 7:41 PM |
| Details | Last Recertification Date | Insert | | | | 3/26/2010 12:32 PM |
| Details | Grant Number | Insert | | | H80CS08752 | 3/26/2010 12:32 PM |
| Details | 340B ID | Insert | | | CHC08752-01 | 3/26/2010 12:32 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 3/26/2010 12:32 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 3/26/2010 12:32 PM |
| Details | Medicare Provider Number | Insert | | | | 3/26/2010 12:32 PM |
| Details | Entity Name | Insert | | | LAKELAND IMMEDIATE CARE CENTER | 3/26/2010 12:32 PM |
| Details | Program Code | Insert | | | CH | 3/26/2010 12:32 PM |
| Details | Entity Subname | Insert | | | CASSOPOLIS FAMILY CLINIC | 3/26/2010 12:32 PM |
| Dates | Participating Approval Date | Insert | | | 3/10/2010 12:00:00 AM | 3/26/2010 12:32 PM |
| Details | State | Insert | | | Active | 3/26/2010 12:32 PM |
| Dates | Registration Date | Insert | | | 2/22/2010 12:00:00 AM | 3/26/2010 12:32 PM |
| Dates | Signed By Date | Insert | | | 1/22/2010 12:00:00 AM | 3/26/2010 12:32 PM |
| Dates | Start Date | Insert | | | 4/1/2010 12:00:00 AM | 3/26/2010 12:32 PM |
| Terminations | Termination Comments | Insert | | | | 3/26/2010 12:32 PM |
| Terminations | Termination Date | Insert | | | | 3/26/2010 12:32 PM |
| Terminations | Termination Effective Date | Insert | | | | 3/26/2010 12:32 PM |
| Terminations | Termination Reason | Insert | | | | 3/26/2010 12:32 PM |