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General NPI Number Information
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NPI Number | 1780480822
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Entity Type | Organization
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Legal Business Name | AQUARIAN MINISTRY LTD SPIRITUALIST CHURCH OF INTEGRATIVE HEALTH
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Dates
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Enumeration Date | 02/20/2025
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Last Update Date | 02/20/2025
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Provider Practice Location Address
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Address Line | GRACE CLINIC 620 8TH AVE
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City | TERRE HAUTE
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State | IN
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Zip | 47804
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Country | US
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Telephone | 812-231-8350
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Fax |
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Provider Business Mailing Address
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Address Line | 858 N LASALLE ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46201-2556
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Country | US
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Telephone | 317-907-4198
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF MEDICINE
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Name | DR. TERESE A POLING
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Credential | MD
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Telephone | 317-907-4198
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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