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General NPI Number Information
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NPI Number | 1164669255
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Entity Type | Organization
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Legal Business Name | BLACKBIRD CLINICAL SERVICES, LLC
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Dates
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Enumeration Date | 01/12/2009
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Last Update Date | 01/12/2009
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Provider Practice Location Address
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Address Line | 2 EXECUTIVE DR STE D
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City | LAFAYETTE
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State | IN
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Zip | 47905-4878
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Country | US
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Telephone | 765-447-8700
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Fax |
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Provider Business Mailing Address
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Address Line | 2 EXECUTIVE DR STE D
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City | LAFAYETTE
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State | IN
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Zip | 47905-4878
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Country | US
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Telephone | 765-447-8700
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ CEO
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Name | MRS. KIMI L. HATHAWAY
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Credential |
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Telephone | 765-447-8700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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