=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740052653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAJESTICS LIFE RESIDENTIAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2023
-----------------------------------------------------
Last Update Date | 10/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E CARMEL DR STE E300
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-606-2888
-----------------------------------------------------
Fax | 317-606-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 E CARMEL DR STE E300
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-606-2888
-----------------------------------------------------
Fax | 317-606-2888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. ALLISON MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-606-2888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------