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General NPI Number Information
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NPI Number | 1255075008
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Entity Type | Organization
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Legal Business Name | INDIANA DETOX LLC
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Dates
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Enumeration Date | 04/26/2022
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Last Update Date | 09/08/2025
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Provider Practice Location Address
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Address Line | 2306 W 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-5219
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Country | US
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Telephone | 812-605-5619
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Fax |
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Provider Business Mailing Address
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Address Line | 2306 W 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-5219
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Country | US
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Telephone | 812-605-5619
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHRISTOPHER FERRY
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Credential |
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Telephone | 812-605-5619
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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