Provider Demographics
NPI:1790964914
Name:INDIANA MOTHERS' MILK BANK, INC
Entity Type:Organization
Organization Name:INDIANA MOTHERS' MILK BANK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NUTTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-329-7146
Mailing Address - Street 1:6820 PARKDALE PL
Mailing Address - Street 2:SUITE 109
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-6601
Mailing Address - Country:US
Mailing Address - Phone:317-329-7146
Mailing Address - Fax:317-329-7151
Practice Address - Street 1:6820 PARKDALE PL
Practice Address - Street 2:SUITE 109
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6601
Practice Address - Country:US
Practice Address - Phone:317-329-7146
Practice Address - Fax:317-329-7151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid