MEDICARE: 8935 EAST 46TH STREET 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1811463060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	8935 EAST 46TH STREET LLC

Provider Business Mailing Address
First Line	:	PO BOX 577
Second Line	:
City	:	EL PRADO
State	:	NM
Zip	:	87529-0577
Country	:	US
Telephone Number	:	208-680-5663
Fax Number	:

Provider Business Practice Location Address
First Line	:	8935 E 46TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-4125
Country	:	US
Telephone Number	:	317-947-0233
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JOHN TUCKER
Credential	:
Telephone Number	:	208-680-5663

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	10/15/2018

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