Provider Demographics
NPI:1285023036
Name:COMMUNITY INTEGRATION SUPPORT SERVICES
Entity Type:Organization
Organization Name:COMMUNITY INTEGRATION SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-201-5090
Mailing Address - Street 1:7560 OLD TRAILS RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6743
Mailing Address - Country:US
Mailing Address - Phone:317-429-9885
Mailing Address - Fax:
Practice Address - Street 1:7560 OLD TRAILS RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6743
Practice Address - Country:US
Practice Address - Phone:317-429-9885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201267110AMedicaid