Provider Demographics
NPI:1982343877
Name:SHORE BEHAVIORAL LLC
Entity Type:Organization
Organization Name:SHORE BEHAVIORAL LLC
Other - Org Name:ETHAN CROSSING ADDICTION CAMPUS OF INDIANAPOLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YITZHAK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-489-7100
Mailing Address - Street 1:10123 ALLIANCE RD
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 SHORE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2608
Practice Address - Country:US
Practice Address - Phone:513-489-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-31
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital