Healthcare Provider Details

I. General information

NPI: 1659062099
Provider Name (Legal Business Name): CEREBROCARE OF INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PROFESSIONAL CT
LAFAYETTE IN
47905-5153
US

IV. Provider business mailing address

34 WELLS DR
FARMINGTON CT
06032-3104
US

V. Phone/Fax

Practice location:
  • Phone: 219-588-8000
  • Fax:
Mailing address:
  • Phone: 860-771-0622
  • Fax: 606-402-2132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRUCE BALLET
Title or Position: EXECUTIVE VP
Credential:
Phone: 860-771-0622