Provider Demographics
NPI:1558485466
Name:MARINERS INN
Entity Type:Organization
Organization Name:MARINERS INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
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 1:445 LEDYARD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2641
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:2007-03-17
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA820152320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI56421819OtherTPIN ASSIGNMENT