Provider Demographics
NPI:1295411817
Name:SPARK RECOVERY OF INDIANA
Entity type:Organization
Organization Name:SPARK RECOVERY OF INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YERUCHEM
Authorized Official - Middle Name:
Authorized Official - Last Name:BIDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-842-3951
Mailing Address - Street 1:9302 N MERIDIAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9302 N MERIDIAN ST STE 101
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1841
Practice Address - Country:US
Practice Address - Phone:317-967-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-27
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children