MEDICARE: ORIGINAL HOUSING PROGRAM

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	261QM0850X	Adult Mental Health Clinic/Center
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1659928794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGINAL HOUSING PROGRAM

Provider Business Mailing Address
First Line	:	3902 N COLLEGE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-2735
Country	:	US
Telephone Number	:	317-258-0302
Fax Number	:

Provider Business Practice Location Address
First Line	:	3539 N COLLEGE AVE # 1
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-3755
Country	:	US
Telephone Number	:	317-258-0302
Fax Number	:

Authorized Official
Title or Position	:	NON CLINICAL
Name	:	LATOYA VINETTIE BEVERLY
Credential	:
Telephone Number	:	317-559-5802

Provider Enumeration Date	:	08/22/2019
Last Update Date	:	08/22/2019

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