Provider Demographics
NPI:1770167405
Name:AMICUS PLACE, LLC.
Entity type:Organization
Organization Name:AMICUS PLACE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:765-425-7794
Mailing Address - Street 1:2427 CEDAR BND
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-1084
Mailing Address - Country:US
Mailing Address - Phone:765-425-7794
Mailing Address - Fax:
Practice Address - Street 1:2427 CEDAR BND
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-1084
Practice Address - Country:US
Practice Address - Phone:765-425-7794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-09
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities