Healthcare Provider Details

I. General information

NPI: 1114482122
Provider Name (Legal Business Name): PRO SURGE INDY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 STATESMEN DR STE B
INDIANAPOLIS IN
46250-5645
US

IV. Provider business mailing address

2413 N MERIDIAN ST
INDIANAPOLIS IN
46208-5854
US

V. Phone/Fax

Practice location:
  • Phone: 480-930-4018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTY MORGAN
Title or Position: MEMBER
Credential: DC
Phone: 623-935-9920