Healthcare Provider Details

I. General information

NPI: 1013593342
Provider Name (Legal Business Name): THEODORE PHILIP MILES CADAC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 W BLOOMFIELD RD
BLOOMINGTON IN
47403-2051
US

IV. Provider business mailing address

1355 W BLOOMFIELD RD
BLOOMINGTON IN
47403-2051
US

V. Phone/Fax

Practice location:
  • Phone: 812-558-0574
  • Fax:
Mailing address:
  • Phone: 812-558-0574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC2-1990
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: