NPIMap

Organization Active NPI

Northeastern Center Inc

  • Community/Behavioral Health Agency
  • Kendallville, IN
National Provider Identifier
1720140908
Registry record updated Feb 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
License
426-0-CMHC Issued in IN
Legal business name
NORTHEASTERN CENTER INC
Practice address
220 S Main St
Kendallville, IN 46755-1718
Phone
(260) 347-2453
Fax
(260) 347-2456
NPI assigned
Dec 14, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeryl Hollister
Title
Ceo
Phone
(260) 347-2453

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X 426-0-CMHC IN Primary

Addresses

Primary practice location

220 S Main St
Kendallville, IN 46755-1718

Mailing address

PO Box 817
Kendallville, IN 46755-0817
Phone (260) 347-2453

Other identifiers 1

IdentifierTypeStateIssuer
100190820AMedicaidIN

Other names 1

  • Northeastern Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040605000289 IN Part B Supplier - Clinic/Group Practice 6709795636 Receives reassigned benefits from 29 practitioners
Practice locations: Kendallville, IN; Lagrange, IN; Auburn, IN; Angola, IN; Albion, IN

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Northeastern Center10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

833 E Main St
Albion, IN 46701
Phone (260) 636-6975

1850 Wesley Rd
Auburn, IN 46706
Phone (260) 925-2453

1800 Wesley Rd
Auburn, IN 46706
Phone (260) 925-2453

1930 Dowling St
Kendallville, IN 46755
Phone (260) 347-4400

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Northeastern CenterAuburn, IN, CCN 154050 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2003

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 55

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 55

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166054400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487635200000",
    "number": "1720140908",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 817",
            "city": "KENDALLVILLE",
            "state": "IN",
            "postal_code": "467550817",
            "telephone_number": "260-347-2453",
            "fax_number": "260-347-2456"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "220 S MAIN ST",
            "city": "KENDALLVILLE",
            "state": "IN",
            "postal_code": "467551718",
            "telephone_number": "260-347-2453",
            "fax_number": "260-347-2456"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEASTERN CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-14",
        "last_updated": "2017-02-21",
        "status": "A",
        "authorized_official_last_name": "HOLLISTER",
        "authorized_official_first_name": "JERYL",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "260-347-2453"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "IN",
            "license": "426-0-CMHC",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100190820A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeastern Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kendallville, IN

Sources for this page

Verify at the official NPI Registry.