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General NPI Number Information
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NPI Number | 1558485466
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Entity Type | Organization
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Legal Business Name | MARINERS INN
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Dates
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Enumeration Date | 03/17/2007
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Last Update Date | 04/20/2018
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Provider Practice Location Address
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Address Line | 445 LEDYARD ST
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City | DETROIT
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State | MI
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Zip | 48201-2641
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Country | US
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Telephone | 313-962-9446
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Fax | 313-962-6395
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Provider Business Mailing Address
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Address Line | 445 LEDYARD ST
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City | DETROIT
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State | MI
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Zip | 48201-2641
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Country | US
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Telephone | 313-962-9446
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Fax | 313-962-6395
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. DAVID SAMPSON
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Credential | LMSW
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Telephone | 313-962-9446
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | SA820152
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License Number State | MI
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