Provider Demographics
NPI:1376919217
Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER, INC
Entity Type:Organization
Organization Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER, INC
Other - Org Name:REGIONAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUMWIED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-736-7183
Mailing Address - Street 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1924
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:3903 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2555
Practice Address - Country:US
Practice Address - Phone:219-398-7050
Practice Address - Fax:219-392-6998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201323280AMedicaid
IN15D2100511OtherCLIA
IN15-1958Medicare PIN