Healthcare Provider Details

I. General information

NPI: 1558629634
Provider Name (Legal Business Name): INDIANA HEALTH CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 FELLOWS ST
SOUTH BEND IN
46601-3514
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-9033
  • Fax: 574-234-9059
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-573-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. TRACY J NAGEL
Title or Position: CFO
Credential:
Phone: 317-576-1335