MEDICARE: INDIANA RE-ENTRY INTEGRATED SERVICES

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1164137659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA RE-ENTRY INTEGRATED SERVICES

Provider Business Mailing Address
First Line	:	3301 BROUSE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-2018
Country	:	US
Telephone Number	:	317-263-6573
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 BROUSE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-2018
Country	:	US
Telephone Number	:	317-263-6573
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL DWAYNE JAMES
Credential	:	LCAC
Telephone Number	:	317-263-6573

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	01/18/2023

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