Healthcare Provider Details

I. General information

NPI: 1538640040
Provider Name (Legal Business Name): 180 DEGREES MENTORING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10608 NASSAU ST
INDIANAPOLIS IN
46234-3183
US

IV. Provider business mailing address

10608 NASSAU ST
INDIANAPOLIS IN
46234-3183
US

V. Phone/Fax

Practice location:
  • Phone: 317-250-1508
  • Fax:
Mailing address:
  • Phone: 317-250-1508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES MAURICE SURRETT
Title or Position: CEO
Credential:
Phone: 317-250-1508