Healthcare Provider Details

I. General information

NPI: 1548274202
Provider Name (Legal Business Name): ALPINE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 ROME DR
LAFAYETTE IN
47905-4488
US

IV. Provider business mailing address

3660 ROME DR
LAFAYETTE IN
47905-4488
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-9394
  • Fax: 765-447-8875
Mailing address:
  • Phone: 765-446-9394
  • Fax: 765-447-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NIZAR EL-KHALILI
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 765-446-9394