Basic Information
| Provider Information | |||||||||
| NPI: | 1932253812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN INDIANA TREATMENT CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6185 PASEO DEL NORTE STE 150 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607100819 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7509 CHARLESTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471119623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122564686 | ||||||||
| FaxNumber: | 8122564415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANDERSON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
| AuthorizedOfficialTelephone: | 8552592288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACADIA HEALTHCARE COMPANY, INC. | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 1076-0-ASR | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261Q00000X | 1076-0-ASR | IN | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM2800X | 1076-0-ASR | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 201387960A | 05 | IN | MEDICAID | 300009020 | 05 | IN | MEDICAID |