Provider Demographics
NPI:1417310335
Name:THE METRO MENTORSHIP INITIATIVE
Entity Type:Organization
Organization Name:THE METRO MENTORSHIP INITIATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-595-4645
Mailing Address - Street 1:1828 N LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-4818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1828 N LOWELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-4818
Practice Address - Country:US
Practice Address - Phone:773-595-4645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization