Provider Demographics
NPI:1538285838
Name:INTERLOCAL COMMUNITY ACTION PROGRAM
Entity Type:Organization
Organization Name:INTERLOCAL COMMUNITY ACTION PROGRAM
Other - Org Name:MOTHER CHILD CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLIVICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-529-4403
Mailing Address - Street 1:1912 BUNDY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-2918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1912 BUNDY AVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-2918
Practice Address - Country:US
Practice Address - Phone:765-521-1401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100134600Medicaid