Healthcare Provider Details

I. General information

NPI: 1144634254
Provider Name (Legal Business Name): SALVATION ARMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
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: 313-361-6211
Mailing address:
  • Phone: 313-361-6136
  • Fax: 313-361-6211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberSA0820103
License Number StateMI

VIII. Authorized Official

Name: MRS. CYNTHIA MAINVILLE
Title or Position: ADMINSTRATOR
Credential:
Phone: 313-361-6136