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General NPI Number Information
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NPI Number | 1790994796
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Entity Type | Organization
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Legal Business Name | CAPITOL CITY RESIDENTIAL HEALTH CARE LLC
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1608 E 10TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46201-1902
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Country | US
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Telephone | 317-632-1851
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Fax | 866-480-7748
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Provider Business Mailing Address
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Address Line | 1608 E 10TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46201-1902
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Country | US
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Telephone | 317-632-1851
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Fax | 866-480-7748
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KELLEE R. DERICO
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Credential |
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Telephone | 317-632-1851
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State | IN
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