Healthcare Provider Details

I. General information

NPI: 1861587230
Provider Name (Legal Business Name): SUCCESS ACQ CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 WEST VERMONT
INDIANAPOLIS IN
46222
US

IV. Provider business mailing address

PO BOX 26456
INDIANAPOLIS IN
46226
US

V. Phone/Fax

Practice location:
  • Phone: 317-916-1402
  • Fax: 317-630-5221
Mailing address:
  • Phone: 317-524-6360
  • Fax: 317-544-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number43661
License Number StateIN

VIII. Authorized Official

Name: CHRIS JAGODITZ
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 317-524-6360