Healthcare Provider Details

I. General information

NPI: 1568296481
Provider Name (Legal Business Name): FISHERS CLINIC AND MED SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13578 E 131ST ST STE 101
FISHERS IN
46037-6401
US

IV. Provider business mailing address

PO BOX 586
GALLOWAY OH
43119-0586
US

V. Phone/Fax

Practice location:
  • Phone: 317-800-7981
  • Fax:
Mailing address:
  • Phone: 765-969-7841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MANDEEP KAPOOR
Title or Position: CEO
Credential: NP
Phone: 646-724-9694