=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902547136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARE ACCESS GROUP, INC-WAIVER SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2022
-----------------------------------------------------
Last Update Date | 04/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4151 E 40TH STREET SOUTH DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46226-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-213-7975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4151 E 40TH STREET SOUTH DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46226-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-213-7975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SHVONNE WATSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-213-7975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------