Healthcare Provider Details

I. General information

NPI: 1841911591
Provider Name (Legal Business Name): FC INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2418 16TH ST
BEDFORD IN
47421-3049
US

IV. Provider business mailing address

PO BOX 306414
NASHVILLE TN
37230-6414
US

V. Phone/Fax

Practice location:
  • Phone: 931-253-1110
  • Fax: 931-722-9919
Mailing address:
  • Phone: 931-253-1110
  • Fax: 931-722-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYDNI CLEMMONS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 901-351-1791