Provider Demographics
NPI:1689781346
Name:NORTHEASTERN CENTER, INC
Entity Type:Organization
Organization Name:NORTHEASTERN CENTER, INC
Other - Org Name:NORTHEASTERN CENTER INPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-347-2453
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-0817
Mailing Address - Country:US
Mailing Address - Phone:260-347-2453
Mailing Address - Fax:260-347-2456
Practice Address - Street 1:1850 WESLEY RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-3653
Practice Address - Country:US
Practice Address - Phone:260-927-0726
Practice Address - Fax:260-927-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN426-18-PIP283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200404950Medicaid
IN000000316878OtherANTHEM PROVIDER NUMBER
IN154050Medicare Oscar/Certification