Healthcare Provider Details

I. General information

NPI: 1619564549
Provider Name (Legal Business Name): 180 ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2020
Last Update Date: 12/27/2020
Certification Date: 12/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 CORK BEND DR
INDIANAPOLIS IN
46239-7669
US

IV. Provider business mailing address

3430 CORK BEND DR
INDIANAPOLIS IN
46239-7669
US

V. Phone/Fax

Practice location:
  • Phone: 317-966-7772
  • Fax:
Mailing address:
  • Phone: 317-966-7772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMTOIYA SAM
Title or Position: OWNER
Credential: LCAC
Phone: 317-966-7772