Provider Demographics
NPI:1649486887
Name:HARBOR LIGHT CENTER, SALVATION ARMY
Entity type:Organization
Organization Name:HARBOR LIGHT CENTER, SALVATION ARMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MERRILL
Authorized Official - Middle Name:D
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:SALVATION ARMY
Authorized Official - Phone:312-667-2266
Mailing Address - Street 1:825 N CHRISTIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-4110
Mailing Address - Country:US
Mailing Address - Phone:312-667-2253
Mailing Address - Fax:312-421-0823
Practice Address - Street 1:825 N CHRISTIANA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-4110
Practice Address - Country:US
Practice Address - Phone:312-667-2253
Practice Address - Fax:312-421-0823
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SALVATION ARMY AN ILLIONIS CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid