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General NPI Number Information
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NPI Number | 1467823880
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Entity Type | Organization
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Legal Business Name | CLINIC AT HOME
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Dates
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Enumeration Date | 10/12/2015
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Last Update Date | 10/12/2015
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Provider Practice Location Address
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Address Line | 14675 CHRISTIE ANN DR
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City | FISHERS
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State | IN
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Zip | 46040-9682
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Country | US
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Telephone | 732-861-3749
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Fax |
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Provider Business Mailing Address
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Address Line | 14675 CHRISTIE ANN DR
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City | FISHERS
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State | IN
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Zip | 46040-9682
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MERCY MOTO
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Credential | NURSE PRACTITIONER
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Telephone | 732-861-3749
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 71004940A
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License Number State | IN
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