MEDICARE: LORI HABERMEHL

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	172A00000X	Driver		IN

General Provider Information

NPI Number	:	1689070310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI HABERMEHL

Provider Business Mailing Address
First Line	:	404 FLOWERY BRANCH CT
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-5548
Country	:	US
Telephone Number	:	317-417-8061
Fax Number	:	317-215-0231

Provider Business Practice Location Address
First Line	:	9465 COUNSELORS ROW
Second Line	:	SUITE 200
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-6423
Country	:	US
Telephone Number	:	317-417-6081
Fax Number	:	317-215-0231

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

Provider Enumeration Date	:	11/06/2014
Last Update Date	:	11/06/2014

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