Provider Demographics
NPI:1518447309
Name:WELLPOINT RECOVERY LLC
Entity Type:Organization
Organization Name:WELLPOINT RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PIRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-771-7108
Mailing Address - Street 1:3930 MEZZANINE DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8646
Mailing Address - Country:US
Mailing Address - Phone:765-771-7108
Mailing Address - Fax:765-269-9569
Practice Address - Street 1:3930 MEZZANINE DR STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8646
Practice Address - Country:US
Practice Address - Phone:765-771-7108
Practice Address - Fax:765-269-9569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty