1366680902 NPI number — BRANCHES OF LIFE FAMILY CONNECTIONS

Table of content: (NPI 1366680902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366680902 NPI number — BRANCHES OF LIFE FAMILY CONNECTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRANCHES OF LIFE FAMILY CONNECTIONS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366680902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4954 E 56TH ST
Provider Second Line Business Mailing Address:
#10
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46220-5773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-449-0334
Provider Business Mailing Address Fax Number:
317-536-1070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4954 E 56TH ST
Provider Second Line Business Practice Location Address:
#10
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46220-5773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-449-0334
Provider Business Practice Location Address Fax Number:
317-536-1070
Provider Enumeration Date:
02/03/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DICKERSON
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT/THERAPIST
Authorized Official Telephone Number:
317-446-4943

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)