Healthcare Provider Details

I. General information

NPI: 1982242327
Provider Name (Legal Business Name): SHALOM HEALTH CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 LAFAYETTE RD MOBILE UNIT
INDIANAPOLIS IN
46222-1146
US

IV. Provider business mailing address

3400 LAFAYETTE RD
INDIANAPOLIS IN
46222-1146
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. LEONARDO R ORTEGA
Title or Position: CEO
Credential: MD, MPH
Phone: 317-291-7422