Healthcare Provider Details

I. General information

NPI: 1811094998
Provider Name (Legal Business Name): SALVATION ARMY-HARBOR LIGHT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 LAWTON ST
DETROIT MI
48208-2500
US

IV. Provider business mailing address

3737 LAWTON ST
DETROIT MI
48208-2500
US

V. Phone/Fax

Practice location:
  • Phone: 313-361-6136
  • Fax: 313-361-6210
Mailing address:
  • Phone: 313-361-6136
  • Fax: 313-361-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number4301061866
License Number StateMI

VIII. Authorized Official

Name: MRS. MICHELLE GATES
Title or Position: QA
Credential:
Phone: 313-361-6136