1164833679 NPI number — INDIANA MATH AND SCIENCE ACADEMY WEST

Table of content: (NPI 1164833679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164833679 NPI number — INDIANA MATH AND SCIENCE ACADEMY WEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA MATH AND SCIENCE ACADEMY WEST
Provider Last Name:
Provider First Name:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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NPI Number Information

NPI Number:
1164833679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4575 W 38TH 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:
46254-3313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4575 W 38TH ST
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:
46254-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-252-3990
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDEN
Authorized Official First Name:
SERQUITTO
Authorized Official Middle Name:
Authorized Official Title or Position:
IMSA REPRESENTATIVE
Authorized Official Telephone Number:
317-252-3990

Provider Taxonomy Codes

  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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