Healthcare Provider Details

I. General information

NPI: 1720824014
Provider Name (Legal Business Name): MR. RADCLIFFE J V GANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 LAFAYETTE RD
INDIANAPOLIS IN
46254-2409
US

IV. Provider business mailing address

4245 LAFAYETTE RD
INDIANAPOLIS IN
46254-2409
US

V. Phone/Fax

Practice location:
  • Phone: 463-248-5072
  • Fax:
Mailing address:
  • Phone: 463-248-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: