MEDICARE: FATSAL SPECTACLE 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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1760229926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FATSAL SPECTACLE LLC

Provider Business Mailing Address
First Line	:	2835 POINTE BAY RD # 46229
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-0003
Country	:	US
Telephone Number	:	317-222-0274
Fax Number	:

Provider Business Practice Location Address
First Line	:	2835 POINTE BAY RD # 46229
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-0003
Country	:	US
Telephone Number	:	317-222-0274
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	MR. BOLAJI SALAHUDEEN IMAM
Credential	:	MD
Telephone Number	:	317-222-0274

Provider Enumeration Date	:	07/13/2024
Last Update Date	:	07/13/2024

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