Provider Demographics
NPI:1174685358
Name:NORTHEASTERN CENTER
Entity Type:Organization
Organization Name:NORTHEASTERN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-347-2453
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-0817
Mailing Address - Country:US
Mailing Address - Phone:260-347-2453
Mailing Address - Fax:260-347-2456
Practice Address - Street 1:220 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1718
Practice Address - Country:US
Practice Address - Phone:260-347-2453
Practice Address - Fax:260-347-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN426-0-CMHC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100190820BMedicaid