Provider Demographics
NPI:1790868040
Name:INDY SPORTS CHIROPRACTIC PC
Entity Type:Organization
Organization Name:INDY SPORTS CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BISESI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-580-0000
Mailing Address - Street 1:75 EXECUTIVE DR STE J
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2993
Mailing Address - Country:US
Mailing Address - Phone:317-580-0000
Mailing Address - Fax:317-927-8621
Practice Address - Street 1:75 EXECUTIVE DR STE J
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2993
Practice Address - Country:US
Practice Address - Phone:317-580-0000
Practice Address - Fax:317-927-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN080001647111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092392OtherANTHEM
INU60247Medicare UPIN