Healthcare Provider Details

I. General information

NPI: 1770321762
Provider Name (Legal Business Name): ELIONNET LUNA RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6450 RODEBAUGH RD
INDIANAPOLIS IN
46268-2562
US

IV. Provider business mailing address

6655 E US HIGHWAY 36
AVON IN
46123-8923
US

V. Phone/Fax

Practice location:
  • Phone: 317-388-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number99125978A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: