Provider Demographics
NPI:1649723628
Name:CLUBHOUSE OF SAINT JOSEPH COUNTY
Entity type:Organization
Organization Name:CLUBHOUSE OF SAINT JOSEPH COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-360-8409
Mailing Address - Street 1:525 OSTEMO PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1023
Mailing Address - Country:US
Mailing Address - Phone:574-360-8409
Mailing Address - Fax:574-966-1443
Practice Address - Street 1:1216 WAYNE ST N
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1036
Practice Address - Country:US
Practice Address - Phone:574-360-8409
Practice Address - Fax:574-966-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No251S00000XAgenciesCommunity/Behavioral Health