Healthcare Provider Details

I. General information

NPI: 1033013966
Provider Name (Legal Business Name): THE GOOD SAMARITAN JATI CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 E WASHINGTON ST STE 128
INDIANAPOLIS IN
46201-4131
US

IV. Provider business mailing address

2104 E WASHINGTON ST STE 128
INDIANAPOLIS IN
46201-4131
US

V. Phone/Fax

Practice location:
  • Phone: 786-865-3586
  • Fax: 617-990-1707
Mailing address:
  • Phone: 786-865-3586
  • Fax: 617-990-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: JACKSON TARAVINE
Title or Position: MEMBER
Credential: PA
Phone: 786-865-3586