Provider Demographics
NPI:1831427699
Name:INDIGO THERAPY SERVICES, INC.
Entity type:Organization
Organization Name:INDIGO THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-508-0505
Mailing Address - Street 1:6817 ACADEMY PARKWAY WEST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4405
Mailing Address - Country:US
Mailing Address - Phone:505-508-0505
Mailing Address - Fax:505-312-8414
Practice Address - Street 1:7103 4TH ST NW
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6641
Practice Address - Country:US
Practice Address - Phone:505-508-0505
Practice Address - Fax:505-508-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-05
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM423225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53321006Medicaid