Provider Demographics
NPI:1740326669
Name:NORTHEASTERN CENTER
Entity type:Organization
Organization Name:NORTHEASTERN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES COORDINATOR
Authorized Official - Prefix:
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 1:220 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1718
Practice Address - Country:US
Practice Address - Phone:260-347-2453
Practice Address - Fax:260-347-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN426-0-CMHC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)