MEDICARE: CLUBHOUSE OF SAINT JOSEPH COUNTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1649723628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLUBHOUSE OF SAINT JOSEPH COUNTY

Provider Business Mailing Address
First Line	:	525 OSTEMO PL
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1023
Country	:	US
Telephone Number	:	574-360-8409
Fax Number	:	574-966-1443

Provider Business Practice Location Address
First Line	:	1216 WAYNE ST N
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46615-1036
Country	:	US
Telephone Number	:	574-360-8409
Fax Number	:	574-966-1443

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MARK DALE BUCHANAN
Credential	:
Telephone Number	:	574-360-8409

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	07/26/2016

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Directions to “CLUBHOUSE OF SAINT JOSEPH COUNTY ” Practice Location

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