Healthcare Provider Details

I. General information

NPI: 1558485466
Provider Name (Legal Business Name): MARINERS INN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 LEDYARD ST
DETROIT MI
48201-2641
US

IV. Provider business mailing address

445 LEDYARD ST
DETROIT MI
48201-2641
US

V. Phone/Fax

Practice location:
  • Phone: 313-962-9446
  • Fax: 313-962-6395
Mailing address:
  • Phone: 313-962-9446
  • Fax: 313-962-6395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberSA820152
License Number StateMI

VIII. Authorized Official

Name: MR. DAVID SAMPSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LMSW
Phone: 313-962-9446