MEDICARE: IMAGINE MASTER ACADEMY

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	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1922295252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINE MASTER ACADEMY

Provider Business Mailing Address
First Line	:	2000 N WELLS ST
Second Line	:	BUILDING 6
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-2495
Country	:	US
Telephone Number	:	260-420-8395
Fax Number	:	260-423-3508

Provider Business Practice Location Address
First Line	:	2000 N WELLS ST
Second Line	:	BUILDING 6
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-2495
Country	:	US
Telephone Number	:	260-420-8395
Fax Number	:	260-423-3508

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	MR. GUY PLATTER
Credential	:
Telephone Number	:	260-420-8395

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	10/01/2007

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