Healthcare Provider Details

I. General information

NPI: 1578685160
Provider Name (Legal Business Name): CHILDPLACE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E 10TH ST
JEFFERSONVILLE IN
47130-7303
US

IV. Provider business mailing address

2420 E 10TH ST
JEFFERSONVILLE IN
47130-7303
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-8248
  • Fax: 812-282-3291
Mailing address:
  • Phone: 812-282-8248
  • Fax: 812-282-3291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number33428 10-900845
License Number StateIN

VIII. Authorized Official

Name: MR. BRIAN G. DAVIS
Title or Position: PROGRAM SUPERVISOR
Credential:
Phone: 812-282-8248