Provider Demographics
NPI:1427373372
Name:SUPER SHOT
Entity Type:Organization
Organization Name:SUPER SHOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACHRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-424-7468
Mailing Address - Street 1:709 CLAY ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2019
Mailing Address - Country:US
Mailing Address - Phone:260-424-7468
Mailing Address - Fax:
Practice Address - Street 1:709 CLAY ST
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2019
Practice Address - Country:US
Practice Address - Phone:260-424-7468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INN/A251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200977620AMedicaid