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General NPI Number Information
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NPI Number | 1609127646
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Entity Type | Organization
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Legal Business Name | MACON MENTOR ACADEMY
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Dates
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Enumeration Date | 10/01/2012
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Last Update Date | 10/01/2012
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Provider Practice Location Address
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Address Line | 3451 N KINGSLEY DR
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City | BLOOMINGTON
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State | IN
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Zip | 47404-1717
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Country | US
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Telephone | 317-480-2949
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Fax | 812-369-4082
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Provider Business Mailing Address
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Address Line | 3451 N KINGSLEY DR
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City | BLOOMINGTON
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State | IN
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Zip | 47404-1717
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Country | US
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Telephone | 317-480-2949
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Fax | 812-369-4082
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JERRY LEE MACON JR.
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Credential | K-12 EDUCATOR (BSW)
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Telephone | 317-480-2949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number |
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License Number State | IN
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