Healthcare Provider Details

I. General information

NPI: 1538543673
Provider Name (Legal Business Name): HARBORTOWN TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2015
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 E MAIN ST
BENTON HARBOR MI
49022-3036
US

IV. Provider business mailing address

1022 E MAIN ST PO BOX 929
BENTON HARBOR MI
49022-3036
US

V. Phone/Fax

Practice location:
  • Phone: 269-926-0015
  • Fax: 269-926-0123
Mailing address:
  • Phone: 269-926-0015
  • Fax: 269-926-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number110093
License Number StateMI

VIII. Authorized Official

Name: HEATHER RAE KORB
Title or Position: CASE MANAGER
Credential:
Phone: 269-926-0015