Healthcare Provider Details

I. General information

NPI: 1043414428
Provider Name (Legal Business Name): NORTHEASTERN CENTER,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 DOWLING ST
KENDALLVILLE IN
46755-9436
US

IV. Provider business mailing address

1930 DOWLING ST
KENDALLVILLE IN
46755-9436
US

V. Phone/Fax

Practice location:
  • Phone: 126-034-7440
  • Fax: 126-034-7312
Mailing address:
  • Phone: 126-034-7440
  • Fax: 126-034-7312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number101YM0800X
License Number StateIN

VIII. Authorized Official

Name: MRS. SUSAN KAMARA
Title or Position: AREA DIRECTOR
Credential: MA,CRC,LPC
Phone: 12603474400