MEDICARE: KETA CROSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1104365865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETA CROSS

Provider Business Mailing Address
First Line	:	4716 ROUND LAKE RD APT H
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-2386
Country	:	US
Telephone Number	:	317-496-4730
Fax Number	:

Provider Business Practice Location Address
First Line	:	4716 ROUND LAKE RD APT H
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-2386
Country	:	US
Telephone Number	:	317-496-4730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	01/13/2021

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Directions to “ KETA CROSS ” Practice Location

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