Provider Demographics
NPI:1619564549
Name:180 ENTERPRISE
Entity Type:Organization
Organization Name:180 ENTERPRISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMTOIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCAC
Authorized Official - Phone:317-966-7772
Mailing Address - Street 1:3430 CORK BEND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-7669
Mailing Address - Country:US
Mailing Address - Phone:317-966-7772
Mailing Address - Fax:
Practice Address - Street 1:3430 CORK BEND DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-7669
Practice Address - Country:US
Practice Address - Phone:317-966-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty