Basic Information
| Provider Information | |||||||||
| NPI: | 1306922174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHOLIC SOCAIL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109879100 | ||||||||
| FaxNumber: | 8109879105 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109879100 | ||||||||
| FaxNumber: | 8109879105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 05/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8109879100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 5101013191 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0N50220 | 05 | MI | MEDICAID |