Basic Information
| Provider Information | |||||||||
| NPI: | 1023642576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC. | ||||||||
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| OtherOrganizationName: | PNW CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8555 TAFT ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197694005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2250 173RD ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463232074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197694005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | SIKORA | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2197571921 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.