Provider Demographics
NPI:1417428400
Name:SPA, INC.
Entity Type:Organization
Organization Name:SPA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZICKEFOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:574-522-8338
Mailing Address - Street 1:23221 OLD US 20 EAST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9772
Mailing Address - Country:US
Mailing Address - Phone:574-522-8338
Mailing Address - Fax:574-742-6118
Practice Address - Street 1:23221 OLD US 20
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9772
Practice Address - Country:US
Practice Address - Phone:574-522-8338
Practice Address - Fax:574-742-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility