Provider Demographics
NPI:1275871451
Name:LAFAYETTE INTEGRATIVE HEALTH CENTER
Entity Type:Organization
Organization Name:LAFAYETTE INTEGRATIVE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:FERRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-414-9930
Mailing Address - Street 1:12 ELSTON RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-7000
Mailing Address - Country:US
Mailing Address - Phone:765-477-7707
Mailing Address - Fax:765-477-7707
Practice Address - Street 1:12 ELSTON RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-7000
Practice Address - Country:US
Practice Address - Phone:765-477-7707
Practice Address - Fax:765-477-7707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002167A111N00000X
208D00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty