1013060714 NPI number — EAST INDIANA TREATMENT CENTER, LLC

Table of content: (NPI 1013060714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013060714 NPI number — EAST INDIANA TREATMENT CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST INDIANA TREATMENT CENTER, 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:
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:
1013060714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6185 PASEO DEL NORTE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92011-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-710-0819
Provider Business Mailing Address Fax Number:
812-539-2368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
816 RUDOLPH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENDALE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47025-8312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-537-1668
Provider Business Practice Location Address Fax Number:
812-537-1625
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
PETER
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT, CTC DIVISION
Authorized Official Telephone Number:
615-721-1297

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  10780ASR , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 10780ASR , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X , with the licence number: 10780ASR , 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: 0279713 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201345410A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3000012052 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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