Provider Demographics
NPI:1386881050
Name:NORTHEAST GUIDANCE CENTER
Entity type:Organization
Organization Name:NORTHEAST GUIDANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-824-8000
Mailing Address - Street 1:12800 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2061
Mailing Address - Country:US
Mailing Address - Phone:313-824-8000
Mailing Address - Fax:313-824-5589
Practice Address - Street 1:12800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2061
Practice Address - Country:US
Practice Address - Phone:313-824-8000
Practice Address - Fax:313-824-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR 120744734409302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization