MEDICARE: ICR INDIANAPOLIS OPERATING SUBSIDIARY, LLC

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	283Q00000X	Psychiatric Hospital
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1558210997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICR INDIANAPOLIS OPERATING SUBSIDIARY, LLC

Provider Business Mailing Address
First Line	:	1209 N ORANGE ST
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19801-1120
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5510 S EMERSON AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46237-2517
Country	:	US
Telephone Number	:	305-361-9115
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DANIEL MOORE
Credential	:
Telephone Number	:	305-361-9115

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	01/27/2026

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