Healthcare Provider Details

I. General information

NPI: 1609667948
Provider Name (Legal Business Name): NICK R BROVIAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260-1927
US

IV. Provider business mailing address

8530 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260-1927
US

V. Phone/Fax

Practice location:
  • Phone: 855-476-1837
  • Fax:
Mailing address:
  • Phone: 855-476-1837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number28186630A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: