MEDICARE: PEJUS, INC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1639316086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEJUS, INC

Provider Business Mailing Address
First Line	:	1515 MAGNAVOX WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1533
Country	:	US
Telephone Number	:	260-459-1551
Fax Number	:	260-459-1451

Provider Business Practice Location Address
First Line	:	1515 MAGNAVOX WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1533
Country	:	US
Telephone Number	:	260-459-1551
Fax Number	:	260-459-1451

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. ERNEST M BEAL JR.
Credential	:	J.D.
Telephone Number	:	260-459-1551

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	01/07/2009

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Directions to “PEJUS, INC ” Practice Location

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