Provider Demographics
NPI:1184835084
Name:MARINERS INN
Entity Type:Organization
Organization Name:MARINERS INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:313-962-9446
Mailing Address - Street 1:445 LEDYARD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2641
Mailing Address - Country:US
Mailing Address - Phone:313-962-9446
Mailing Address - Fax:313-962-6395
Practice Address - Street 1:14108 MARK TWAIN ST
Practice Address - Street 2:445 LEDYARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2835
Practice Address - Country:US
Practice Address - Phone:313-962-9446
Practice Address - Fax:313-962-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820152324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI820152OtherSUBSTANCE ABUSE