Healthcare Provider Details

I. General information

NPI: 1255188587
Provider Name (Legal Business Name): IIPUC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 N CAPITOL AVE
INDIANAPOLIS IN
46202-6403
US

IV. Provider business mailing address

PO BOX 186
LEBANON IN
46052-0186
US

V. Phone/Fax

Practice location:
  • Phone: 317-920-1111
  • Fax:
Mailing address:
  • Phone: 463-224-3210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: CHERYL GRAHAM
Title or Position: DNP
Credential: NP
Phone: 463-224-3210