1649723628 NPI number — CLUBHOUSE OF SAINT JOSEPH COUNTY

Table of content: (NPI 1649723628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649723628 NPI number — CLUBHOUSE OF SAINT JOSEPH COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLUBHOUSE OF SAINT JOSEPH COUNTY
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:
1649723628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 OSTEMO PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-360-8409
Provider Business Mailing Address Fax Number:
574-966-1443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1216 WAYNE ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46615-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-360-8409
Provider Business Practice Location Address Fax Number:
574-966-1443
Provider Enumeration Date:
07/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BUCHANAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
574-360-8409

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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