Healthcare Provider Details

I. General information

NPI: 1003275512
Provider Name (Legal Business Name): SHALOM HEALTH CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W 56TH ST
INDIANAPOLIS IN
46254-1695
US

IV. Provider business mailing address

3400 LAFAYETTE RD STE 200
INDIANAPOLIS IN
46222-1147
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-7422
  • Fax: 317-291-4912
Mailing address:
  • Phone: 317-291-7422
  • Fax: 317-291-4912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LEONARDO R ORTEGA
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential: M.D., M.P.H.
Phone: 317-291-7422