Healthcare Provider Details

I. General information

NPI: 1336343797
Provider Name (Legal Business Name): QUANTIS HAWKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 N TREMONT ST
INDIANAPOLIS IN
46222-3734
US

IV. Provider business mailing address

541 N TREMONT ST
INDIANAPOLIS IN
46222-3734
US

V. Phone/Fax

Practice location:
  • Phone: 317-635-5133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: