Healthcare Provider Details

I. General information

NPI: 1184835084
Provider Name (Legal Business Name): MARINERS INN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14108 MARK TWAIN ST 445 LEDYARD
DETROIT MI
48227-2835
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 Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number820152
License Number StateMI

VIII. Authorized Official

Name: MR. DAVID SAMPSON
Title or Position: DEPUTY DIRECTOR
Credential: MSW
Phone: 313-962-9446