Healthcare Provider Details

I. General information

NPI: 1326801879
Provider Name (Legal Business Name): EASTGATE CHRISTIAN CHURCH DBA AUTUMN LEAVES OF EASTGATE ADULT DAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 E 16TH ST
INDIANAPOLIS IN
46219-2801
US

IV. Provider business mailing address

8100 E 16TH ST
INDIANAPOLIS IN
46219-2801
US

V. Phone/Fax

Practice location:
  • Phone: 317-820-3233
  • Fax:
Mailing address:
  • Phone: 317-820-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SCHELLIE CLEMONS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 317-820-3233