Provider Demographics
NPI:1275701633
Name:WHITE RIVER DEVELOPMENT GROUP, INC.
Entity Type:Organization
Organization Name:WHITE RIVER DEVELOPMENT GROUP, INC.
Other - Org Name:THE COMPLEMENTARY MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-885-3677
Mailing Address - Street 1:1250 E COUNTY LINE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1004
Mailing Address - Country:US
Mailing Address - Phone:317-885-3677
Mailing Address - Fax:317-885-3678
Practice Address - Street 1:1250 E COUNTY LINE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1004
Practice Address - Country:US
Practice Address - Phone:317-885-3677
Practice Address - Fax:317-885-3678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000465A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71000465OtherLICENSE
IN595590HHHOtherMEDICARE ID
IN71000465OtherLICENSE