Basic Information
| Provider Information | |||||||||
| NPI: | 1073058772 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERIDIAN HEALTH SERVICES CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESIDENTIAL SUBSTANCE ABUSE TREATMENT PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410335 | ||||||||
| Practice Location | |||||||||
| Address1: | 498 NW 18TH ST BLDG 416 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2017 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHAFER | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO/VP | ||||||||
| AuthorizedOfficialTelephone: | 7652881928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.