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General NPI Number Information
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NPI Number | 1063612257
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Entity Type | Organization
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Legal Business Name | INDIANA STATE UNIVERSITY
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Dates
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Enumeration Date | 07/25/2007
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Last Update Date | 04/11/2017
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Provider Practice Location Address
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Address Line | 567 N 5TH ST.
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City | TERRE HAUTE
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State | IN
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Zip | 47809
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Country | US
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Telephone | 812-237-9613
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Fax | 812-237-9612
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Provider Business Mailing Address
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Address Line | 567 N 5TH ST.
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City | TERRE HAUTE
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State | IN
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Zip | 47809
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Country | US
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Telephone | 812-237-9613
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Fax | 812-237-9612
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Authorized Official
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Title or Position | INTERIM PT DIRECTOR
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Name | MR. FRED LUSTER
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Credential | PT
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Telephone | 812-237-9613
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 05009329A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 05010420A
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License Number State | IN
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