=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306897004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2006
-----------------------------------------------------
Last Update Date | 10/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 E STATE BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46805-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-481-2700
-----------------------------------------------------
Fax | 260-481-2717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11109 PARKVIEW PLAZA DRIVE MAILBOX 117
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-373-9700
-----------------------------------------------------
Fax | 260-373-9740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR ENTERPRISE CREDENTIALING &
-----------------------------------------------------
Name | KRIS BIGELOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 260-266-1403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 419-0-CMHC
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------