Healthcare Provider Details

I. General information

NPI: 1457984064
Provider Name (Legal Business Name): HEROH FUNCTIONAL INSTITUTE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8425 CASTLETON CORNER DR
INDIANAPOLIS IN
46250-3580
US

IV. Provider business mailing address

6390 SPRING MILL RD
INDIANAPOLIS IN
46260-4242
US

V. Phone/Fax

Practice location:
  • Phone: 317-400-5853
  • Fax: 317-947-0909
Mailing address:
  • Phone: 309-287-9628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. B JERMAINE WARE
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 317-400-5853