Healthcare Provider Details

I. General information

NPI: 1013060714
Provider Name (Legal Business Name): EAST INDIANA TREATMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 RUDOLPH WAY
GREENDALE IN
47025-8312
US

IV. Provider business mailing address

6185 PASEO DEL NORTE STE 150
CARLSBAD CA
92011-1155
US

V. Phone/Fax

Practice location:
  • Phone: 812-537-1668
  • Fax: 812-537-1625
Mailing address:
  • Phone: 760-710-0819
  • Fax: 812-539-2368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number10780ASR
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number10780ASR
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number10780ASR
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0279713
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier201345410A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 3
Identifier3000012052
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: PETER F MORRIS
Title or Position: PRESIDENT, CTC DIVISION
Credential:
Phone: 615-721-1297