Provider Demographics
NPI:1093938102
Name:INTERDISCIPLINARY DIAGNOSTIC AND EVALUATION CENTER, INC.
Entity Type:Organization
Organization Name:INTERDISCIPLINARY DIAGNOSTIC AND EVALUATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:765-284-9573
Mailing Address - Street 1:3030 LAKE AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-422-2838
Mailing Address - Fax:
Practice Address - Street 1:3030 LAKE AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-422-2838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities