Provider Demographics
NPI:1306922174
Name:CATHOLIC SOCAIL SERVICES
Entity type:Organization
Organization Name:CATHOLIC SOCAIL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-987-9100
Mailing Address - Street 1:2601 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6546
Mailing Address - Country:US
Mailing Address - Phone:810-987-9100
Mailing Address - Fax:810-987-9105
Practice Address - Street 1:2601 13TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6546
Practice Address - Country:US
Practice Address - Phone:810-987-9100
Practice Address - Fax:810-987-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013191261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N50220Medicaid