Provider Demographics
NPI:1164669255
Name:BLACKBIRD CLINICAL SERVICES, LLC
Entity Type:Organization
Organization Name:BLACKBIRD CLINICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-447-8700
Mailing Address - Street 1:2 EXECUTIVE DR STE D
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4878
Mailing Address - Country:US
Mailing Address - Phone:765-447-8700
Mailing Address - Fax:
Practice Address - Street 1:2 EXECUTIVE DR STE D
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4878
Practice Address - Country:US
Practice Address - Phone:765-447-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare