Healthcare Provider Details

I. General information

NPI: 1417553777
Provider Name (Legal Business Name): NORTHSHORE HEALTH CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 165TH ST STE A
HAMMOND IN
46320-2823
US

IV. Provider business mailing address

PO BOX 1430
PORTAGE IN
46368-9230
US

V. Phone/Fax

Practice location:
  • Phone: 219-764-5349
  • Fax: 219-764-5381
Mailing address:
  • Phone: 219-763-8112
  • Fax: 219-764-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID HALL
Title or Position: CEO
Credential:
Phone: 219-763-8112