Healthcare Provider Details

I. General information

NPI: 1811718471
Provider Name (Legal Business Name): OUTREACH ADVOCACY CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 FERRY ST STE B
LAFAYETTE IN
47904-3060
US

IV. Provider business mailing address

2300 FERRY ST STE B
LAFAYETTE IN
47904-3060
US

V. Phone/Fax

Practice location:
  • Phone: 765-237-8894
  • Fax:
Mailing address:
  • Phone: 765-237-8894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAIGE LOGAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 765-237-8894