1275011355 NPI number — CLOVER LLC

Table of content: (NPI 1275011355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275011355 NPI number — CLOVER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLOVER LLC
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:
6
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:
1275011355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9765 RANDALL DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46280-1817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-366-2587
Provider Business Mailing Address Fax Number:
317-536-3497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9765 RANDALL DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46280-1817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-366-2587
Provider Business Practice Location Address Fax Number:
317-536-3497
Provider Enumeration Date:
08/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TIDWELL
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
844-366-2587

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  18-013565 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300006917 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300071957 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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