Healthcare Provider Details

I. General information

NPI: 1497058226
Provider Name (Legal Business Name): HTC OUTPATIENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 12/16/2010
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 P.O. 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 Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number110105
License Number StateMI

VIII. Authorized Official

Name: MR. DARIEN L. SMITH LAMARCK SMITH
Title or Position: MEMBER
Credential:
Phone: 269-926-0015