Basic Information
| Provider Information | |||||||||
| NPI: | 1124111703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESOLUTE ACQ COR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 N TIBBS AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462224064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176305215 | ||||||||
| FaxNumber: | 3176305221 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 NORTH TIBBS AVENUE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176305215 | ||||||||
| FaxNumber: | 3176305221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | STURM | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3177576577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 3350649900941 | IN | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 323P00000X | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 200507720B | 05 | IN | MEDICAID |