1790868040 NPI number — INDY SPORTS CHIROPRACTIC PC

Table of content: (NPI 1790868040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790868040 NPI number — INDY SPORTS CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDY SPORTS CHIROPRACTIC PC
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:
1790868040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 EXECUTIVE DR STE J
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:
46032-2993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-580-0000
Provider Business Mailing Address Fax Number:
317-927-8621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 EXECUTIVE DR STE J
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:
46032-2993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-580-0000
Provider Business Practice Location Address Fax Number:
317-927-8621
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BISESI
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
317-580-0000

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  080001647 , 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: 000000092392 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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