Basic Information
| Provider Information | |||||||||
| NPI: | 1396915369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILDREN'S CAMPUS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 LINCOLNWAY W | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465441626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595666 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466173109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742802082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | ERMETI | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5742595667 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 43714 | IN | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 200473490 | 05 | IN | MEDICAID |