MEDICARE: BRANCHES OF LIFE TREATMENT FOSTER CARE INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063724573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANCHES OF LIFE TREATMENT FOSTER CARE INCORPORATED

Provider Business Mailing Address
First Line	:	4954 E 56TH ST
Second Line	:	SUITE 11
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5773
Country	:	US
Telephone Number	:	317-513-8069
Fax Number	:	317-926-0603

Provider Business Practice Location Address
First Line	:	4954 E 56TH ST
Second Line	:	SUITE 11
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5773
Country	:	US
Telephone Number	:	317-513-8069
Fax Number	:	317-926-0603

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SHAWNA WEBSTER
Credential	:
Telephone Number	:	317-513-8069

Provider Enumeration Date	:	07/13/2010
Last Update Date	:	07/13/2010

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