1679895718 NPI number — UNLOCKING THE SPECTRUM

Table of content: (NPI 1679895718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679895718 NPI number — UNLOCKING THE SPECTRUM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNLOCKING THE SPECTRUM
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:
1679895718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5556 N MERIDIAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46208-2658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-334-7331
Provider Business Mailing Address Fax Number:
317-334-7336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8646 GUION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46268-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-334-7331
Provider Business Practice Location Address Fax Number:
317-334-7336
Provider Enumeration Date:
02/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ-RITTER
Authorized Official First Name:
ILANA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
FOUNDER
Authorized Official Telephone Number:
812-606-4413

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 300023751 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201411430A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201190880A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300023732 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300023734 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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