Provider Demographics
NPI:1235494006
Name:INDIANA FAIR CHANCE LLC
Entity Type:Organization
Organization Name:INDIANA FAIR CHANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LSW MBA
Authorized Official - Phone:317-418-7840
Mailing Address - Street 1:7437 COBBLESTONE EAST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9108
Mailing Address - Country:US
Mailing Address - Phone:317-418-7840
Mailing Address - Fax:
Practice Address - Street 1:7437 COBBLESTONE EAST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-9108
Practice Address - Country:US
Practice Address - Phone:317-418-7840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201068830 AOtherWAIVER PROVIDER