MEDICARE: MR. ROGER LEE HIGGINS JR.

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1750538427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER LEE HIGGINS JR.

Provider Business Mailing Address
First Line	:	6104 W LAKE SOUTH DR
Second Line	:	APT A
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-7647
Country	:	US
Telephone Number	:	317-603-2694
Fax Number	:

Provider Business Practice Location Address
First Line	:	6104 W LAKE SOUTH DR
Second Line	:	APT A
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-7647
Country	:	US
Telephone Number	:	317-603-2694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2008
Last Update Date	:	08/25/2008

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