Provider Demographics
NPI:1811094998
Name:SALVATION ARMY-HARBOR LIGHT
Entity type:Organization
Organization Name:SALVATION ARMY-HARBOR LIGHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QA
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-361-6136
Mailing Address - Street 1:3737 LAWTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2500
Mailing Address - Country:US
Mailing Address - Phone:313-361-6136
Mailing Address - Fax:313-361-6210
Practice Address - Street 1:3737 LAWTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2500
Practice Address - Country:US
Practice Address - Phone:313-361-6136
Practice Address - Fax:313-361-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 261QR0800X, 385H00000X
MI4301061866324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251B00000XAgenciesCase Management
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4701194Medicaid