Healthcare Provider Details

I. General information

NPI: 1417630336
Provider Name (Legal Business Name): INDIANA PAIN AND WELLNESS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W 96TH ST STE C
INDIANAPOLIS IN
46260-1193
US

IV. Provider business mailing address

1305 W 96TH ST STE C
INDIANAPOLIS IN
46260-1193
US

V. Phone/Fax

Practice location:
  • Phone: 317-580-9867
  • Fax:
Mailing address:
  • Phone: 317-580-9867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY JO JOHNSON
Title or Position: OWNER
Credential: SC
Phone: 317-580-9867