Basic Information
Provider Information
NPI: 1003141698
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ALIRE
FirstName: MARIETTA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5980 W 71ST ST STE 102
Address2:  
City: INDIANAPOLIS
State: IN
PostalCode: 462781785
CountryCode: US
TelephoneNumber: 3173880800
FaxNumber: 3173880805
Practice Location
Address1: 5980 W 71ST ST STE 102
Address2:  
City: INDIANAPOLIS
State: IN
PostalCode: 462781785
CountryCode: US
TelephoneNumber: 3173880800
FaxNumber: 3173880805
Other Information
ProviderEnumerationDate: 10/15/2009
LastUpdateDate: 10/15/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171W00000X027231-1NYY Other Service ProvidersContractor 

No ID Information.


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