Provider Demographics
NPI:1851612774
Name:INDIANA CLINIC
Entity Type:Organization
Organization Name:INDIANA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:ACSW
Authorized Official - Phone:317-962-5148
Mailing Address - Street 1:1701 N SENATE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5306
Mailing Address - Country:US
Mailing Address - Phone:317-962-5148
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5306
Practice Address - Country:US
Practice Address - Phone:317-962-5148
Practice Address - Fax:317-963-5424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital