Healthcare Provider Details

I. General information

NPI: 1083420491
Provider Name (Legal Business Name): PEYTON FALLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9905 FALL CREEK RD
INDIANAPOLIS IN
46256-4804
US

IV. Provider business mailing address

27777 INKSTER RD STE 100
FARMINGTON HILLS MI
48334-5312
US

V. Phone/Fax

Practice location:
  • Phone: 317-813-4690
  • Fax:
Mailing address:
  • Phone: 248-436-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number26-8602-1221682
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: