Healthcare Provider Details

I. General information

NPI: 1679407829
Provider Name (Legal Business Name): REMORA BAY CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SPENCER LN
BIG SANDY TN
38221-4012
US

IV. Provider business mailing address

500 SPENCER LN
BIG SANDY TN
38221-4012
US

V. Phone/Fax

Practice location:
  • Phone: 317-430-0140
  • Fax: 317-430-0140
Mailing address:
  • Phone: 317-430-0140
  • Fax: 317-430-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MR. DALLAS RICHARDSON
Title or Position: CIO
Credential:
Phone: 317-430-0140