1134341092 NPI number — NCADD-IMPACT ADOLESCENT HEALTH CENTER

Table of content: (NPI 1134341092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134341092 NPI number — NCADD-IMPACT ADOLESCENT HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NCADD-IMPACT ADOLESCENT HEALTH CENTER
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:
Provider Other Organization Name Type Code:
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:
1134341092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
488 FRAZIER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVER ROUGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48218-1025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-551-3815
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5555 CONNER ST
Provider Second Line Business Practice Location Address:
2000 NORTH
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48213-3448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-921-8102
Provider Business Practice Location Address Fax Number:
313-921-4184
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCGLOTHIAN
Authorized Official First Name:
LAVERNE
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
313-921-8102

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  C1820235935 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com