Provider Demographics
NPI:1598389991
Name:INDIANA IMMUNIZATION COALITION INC
Entity Type:Organization
Organization Name:INDIANA IMMUNIZATION COALITION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:317-679-2309
Mailing Address - Street 1:6919 E 10TH ST STE C2
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4811
Mailing Address - Country:US
Mailing Address - Phone:317-679-2309
Mailing Address - Fax:800-285-1013
Practice Address - Street 1:6919 E 10TH ST STE C2
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4811
Practice Address - Country:US
Practice Address - Phone:317-679-2309
Practice Address - Fax:800-285-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-01
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare