Provider Demographics
NPI:1033363668
Name:THE MARY LANE CENTER, LLC
Entity Type:Organization
Organization Name:THE MARY LANE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMANIL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-980-2440
Mailing Address - Street 1:4859 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-2623
Mailing Address - Country:US
Mailing Address - Phone:219-980-2440
Mailing Address - Fax:219-980-3451
Practice Address - Street 1:4859 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2623
Practice Address - Country:US
Practice Address - Phone:219-980-2440
Practice Address - Fax:219-980-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200913570AMedicaid