Provider Demographics
NPI:1689119729
Name:THE SALVATION ARMY HARBOR LIGHT MACOMB
Entity Type:Organization
Organization Name:THE SALVATION ARMY HARBOR LIGHT MACOMB
Other - Org Name:SALVATION ARMY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SITE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-954-1838
Mailing Address - Street 1:42950 STEPNITZ
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036
Mailing Address - Country:US
Mailing Address - Phone:586-954-1838
Mailing Address - Fax:586-954-9856
Practice Address - Street 1:42950 STEPNITZ DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036
Practice Address - Country:US
Practice Address - Phone:586-954-1838
Practice Address - Fax:586-954-9856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0500049324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI192055Medicaid