1689781346 NPI number — NORTHEASTERN CENTER, INC

Table of content: (NPI 1689781346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689781346 NPI number — NORTHEASTERN CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEASTERN 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:
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:
1689781346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENDALLVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46755-0817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-347-2453
Provider Business Mailing Address Fax Number:
260-347-2456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 WESLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46706-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-927-0726
Provider Business Practice Location Address Fax Number:
260-927-0760
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUNKLE
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE SERVICES COORDINATOR
Authorized Official Telephone Number:
260-347-2453

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  426-18-PIP , 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)

  • Identifier: 200404950 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000316878 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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