Healthcare Provider Details

I. General information

NPI: 1629131123
Provider Name (Legal Business Name): CENTRAL INDIANA ORTHOPEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

IV. Provider business mailing address

PO BOX 1643
MUNCIE IN
47308-1643
US

V. Phone/Fax

Practice location:
  • Phone: 765-284-7738
  • Fax:
Mailing address:
  • Phone: 765-284-7738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000201A
License Number StateIN

VIII. Authorized Official

Name: MR. VICTOR MORAN
Title or Position: CEO
Credential:
Phone: 765-284-7738