Healthcare Provider Details

I. General information

NPI: 1114395647
Provider Name (Legal Business Name): INDIANA HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 S LAFOUNTAIN ST
KOKOMO IN
46902-3710
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 765-864-4160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number28171905A
License Number StateIN

VIII. Authorized Official

Name: TERRANCE DRAKE
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 317-576-1335