Healthcare Provider Details

I. General information

NPI: 1669308508
Provider Name (Legal Business Name): RAYNA'S CLUBHOUSE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 ROYAL LAKE DR
INDIANAPOLIS IN
46228-1380
US

IV. Provider business mailing address

1445 ROYAL LAKE DR
INDIANAPOLIS IN
46228-1380
US

V. Phone/Fax

Practice location:
  • Phone: 317-308-0699
  • Fax: 317-308-0699
Mailing address:
  • Phone: 317-308-0699
  • Fax: 317-308-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: VIVIAN RAE BROOKS
Title or Position: CEO
Credential: BROOKS
Phone: 317-308-0699