Healthcare Provider Details

I. General information

NPI: 1689653982
Provider Name (Legal Business Name): CITIZENS HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 N COLLEGE AVE
INDIANAPOLIS IN
46202-1715
US

IV. Provider business mailing address

1650 N COLLEGE AVE
INDIANAPOLIS IN
46202-1715
US

V. Phone/Fax

Practice location:
  • Phone: 317-924-6351
  • Fax: 317-927-3634
Mailing address:
  • Phone: 317-924-6351
  • Fax: 317-927-3634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number50000856A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number60003640A
License Number StateIN

VIII. Authorized Official

Name: MR. RON GIBSON
Title or Position: CEO
Credential:
Phone: 317-396-0279