Provider Demographics
NPI:1659928794
Name:ORIGINAL HOUSING PROGRAM
Entity Type:Organization
Organization Name:ORIGINAL HOUSING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NON CLINICAL
Authorized Official - Prefix:
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:VINETTIE
Authorized Official - Last Name:BEVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-559-5802
Mailing Address - Street 1:3902 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2735
Mailing Address - Country:US
Mailing Address - Phone:317-258-0302
Mailing Address - Fax:
Practice Address - Street 1:3539 N COLLEGE AVE # 1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3755
Practice Address - Country:US
Practice Address - Phone:317-258-0302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health