Healthcare Provider Details

I. General information

NPI: 1720447279
Provider Name (Legal Business Name): INDIGO HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1693 MAIN ST SUITE A
SARASOTA FL
34236-5864
US

IV. Provider business mailing address

12929 LA ROCHELLE CIR
PALM BEACH GARDENS FL
33410-1406
US

V. Phone/Fax

Practice location:
  • Phone: 941-915-6395
  • Fax:
Mailing address:
  • Phone: 941-915-6395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberME60327
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW10574
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberARNP9245432
License Number StateFL

VIII. Authorized Official

Name: SHEILA BRION
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 941-915-6395