Basic Information
| Provider Information | |||||||||
| NPI: | 1821765884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRE INDIANA HEALTH INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASPIRE INDIANA HEALTH - MADISON-GRANT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9615 E 148TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460604371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175741254 | ||||||||
| FaxNumber: | 3176740060 | ||||||||
| Practice Location | |||||||||
| Address1: | 11700 S E 00 W | ||||||||
| Address2: | |||||||||
| City: | FAIRMOUNT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469289318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175741254 | ||||||||
| FaxNumber: | 3176740060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2021 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CROCKETT | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3175870517 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.