1811134588 NPI number — SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811134588 NPI number — SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REGIONAL MENTAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811134588
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8400 LOUISIANA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRILLVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46410-6385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-757-1928
Provider Business Mailing Address Fax Number:
219-757-1950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8555 TAFT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-6123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-769-4005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KRUMWIED
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
219-757-1970

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100200020A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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