Provider Demographics
NPI:1679623235
Name:CORINTHIAN CHRISTIAN CENTER
Entity type:Organization
Organization Name:CORINTHIAN CHRISTIAN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-662-2224
Mailing Address - Street 1:PO BOX 9135
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-9135
Mailing Address - Country:US
Mailing Address - Phone:219-885-5819
Mailing Address - Fax:219-661-8892
Practice Address - Street 1:667 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-2240
Practice Address - Country:US
Practice Address - Phone:219-885-5819
Practice Address - Fax:219-661-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040617A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN404860Medicare ID - Type Unspecified