Provider Demographics
NPI:1912343690
Name:THEODORE CARL DREAM CENTER
Entity Type:Organization
Organization Name:THEODORE CARL DREAM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TEUNESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DD, MA
Authorized Official - Phone:269-838-6528
Mailing Address - Street 1:5 ENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-4317
Mailing Address - Country:US
Mailing Address - Phone:269-962-1337
Mailing Address - Fax:269-962-1364
Practice Address - Street 1:5 ENWOOD ST
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-4317
Practice Address - Country:US
Practice Address - Phone:269-962-1337
Practice Address - Fax:269-962-1364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
MI130118324500000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children