Provider Demographics
NPI:1659851905
Name:THE SALVATION ARMY, AN ILLINOIS CORPORATION
Entity Type:Organization
Organization Name:THE SALVATION ARMY, AN ILLINOIS CORPORATION
Other - Org Name:THE HARBOR LIGHT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:BRAMWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-2000
Mailing Address - Street 1:2400 N TIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2458
Mailing Address - Country:US
Mailing Address - Phone:317-972-1450
Mailing Address - Fax:317-972-1075
Practice Address - Street 1:2400 N TIBBS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-2458
Practice Address - Country:US
Practice Address - Phone:317-972-1450
Practice Address - Fax:317-972-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN324500000XMedicaid