Provider Demographics
NPI:1013060714
Name:EAST INDIANA TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:EAST INDIANA TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CTC DIVISION
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:F
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-721-1297
Mailing Address - Street 1:6185 PASEO DEL NORTE STE 150
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1155
Mailing Address - Country:US
Mailing Address - Phone:760-710-0819
Mailing Address - Fax:812-539-2368
Practice Address - Street 1:816 RUDOLPH WAY
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:IN
Practice Address - Zip Code:47025-8312
Practice Address - Country:US
Practice Address - Phone:812-537-1668
Practice Address - Fax:812-537-1625
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACADIA HEALTHCARE COMPANY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10780ASR261Q00000X, 261QM2800X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0279713Medicaid
IN201345410AMedicaid
IN3000012052Medicaid