Provider Demographics
NPI:1861813685
Name:DETROIT CENTRAL CITY COMMUNITY MENTAL HEALTH, INC.
Entity Type:Organization
Organization Name:DETROIT CENTRAL CITY COMMUNITY MENTAL HEALTH, INC.
Other - Org Name:CENTRAL CITY INTEGRATED HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-733-1302
Mailing Address - Street 1:10 PETERBORO ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2722
Mailing Address - Country:US
Mailing Address - Phone:313-831-3160
Mailing Address - Fax:313-826-0567
Practice Address - Street 1:10 PETERBORO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-578-6123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-20
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-1020Medicare PIN
MI1691432Medicaid