Healthcare Provider Details

I. General information

NPI: 1609145648
Provider Name (Legal Business Name): EASTSIDE SUBSTANCE ABUSE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E SHERMAN BLVD
MUSKEGON HEIGHTS MI
49444-2203
US

IV. Provider business mailing address

445 E SHERMAN BLVD
MUSKEGON HEIGHTS MI
49444-2203
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-4359
  • Fax: 231-733-6151
Mailing address:
  • Phone: 231-739-4359
  • Fax: 231-733-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberL2010754
License Number StateMI

VIII. Authorized Official

Name: DR. LEON SMITH
Title or Position: CEO
Credential: D.O.
Phone: 231-739-4359