1306845185 NPI number — DISCOVERY HOUSE GROUP

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 1306845185 NPI number — DISCOVERY HOUSE GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISCOVERY HOUSE GROUP
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:
6
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:
1306845185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 PAVILION AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-1522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-780-2300
Provider Business Mailing Address Fax Number:
401-780-2397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4195 CLEVELAND ST
Provider Second Line Business Practice Location Address:
RANBURN WOODS PLAZA
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46408-2427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-985-8144
Provider Business Practice Location Address Fax Number:
219-985-8146
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
401-780-2300

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  1397-0-ASR , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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