Healthcare Provider Details

I. General information

NPI: 1073405270
Provider Name (Legal Business Name): PARK CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E STATE BLVD
FORT WAYNE IN
46805-3404
US

IV. Provider business mailing address

1450 PRODUCTION RD
FORT WAYNE IN
46808-1167
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-9125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STANTON RISSER
Title or Position: ACFO
Credential:
Phone: 260-266-9380