Provider Demographics
NPI:1649733148
Name:HARBOR HALL, INC.
Entity type:Organization
Organization Name:HARBOR HALL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-347-5511
Mailing Address - Street 1:704 EMMET ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2910
Mailing Address - Country:US
Mailing Address - Phone:231-347-5511
Mailing Address - Fax:
Practice Address - Street 1:114 RUSH ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2920
Practice Address - Country:US
Practice Address - Phone:231-347-5511
Practice Address - Fax:231-347-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISA0240037Medicaid