1275701633 NPI number — WHITE RIVER DEVELOPMENT GROUP, INC.

Table of content: (NPI 1275701633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275701633 NPI number — WHITE RIVER DEVELOPMENT GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE RIVER DEVELOPMENT GROUP, INC.
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:
1275701633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 E COUNTY LINE RD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46227-1004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-885-3677
Provider Business Mailing Address Fax Number:
317-885-3678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 E COUNTY LINE RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-885-3677
Provider Business Practice Location Address Fax Number:
317-885-3678
Provider Enumeration Date:
02/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
SUSIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
317-885-3677

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71000465A , 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: 71000465 . This is a "LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 595590HHH . This is a "MEDICARE ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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