Provider Demographics
NPI:1457984064
Name:HEROH FUNCTIONAL INSTITUTE PC
Entity Type:Organization
Organization Name:HEROH FUNCTIONAL INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:B JERMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-400-5853
Mailing Address - Street 1:6390 SPRING MILL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-4242
Mailing Address - Country:US
Mailing Address - Phone:309-287-9628
Mailing Address - Fax:
Practice Address - Street 1:8425 CASTLETON CORNER DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3580
Practice Address - Country:US
Practice Address - Phone:317-400-5853
Practice Address - Fax:317-947-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service