Provider Demographics
NPI:1932391125
Name:GLENDALE CHIROPRACTIC P.C.
Entity Type:Organization
Organization Name:GLENDALE CHIROPRACTIC P.C.
Other - Org Name:HEALTHSOURCE OF INDIANAPOLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORTUNATO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-257-2225
Mailing Address - Street 1:6301 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-257-2225
Mailing Address - Fax:317-257-0646
Practice Address - Street 1:6301 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-257-2225
Practice Address - Fax:317-257-0646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2013-01-31
Deactivation Date:2008-04-15
Deactivation Code:
Reactivation Date:2008-05-20
Provider Licenses
StateLicense IDTaxonomies
IN08001070111N00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100120180Medicaid
IN91939OtherANTHEM
IN91939OtherANTHEM
IN100120180Medicaid