Basic Information
| Provider Information | |||||||||
| NPI: | 1306897004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARK CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DRIVE | ||||||||
| Address2: | MAILBOX 117 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 E STATE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468053404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604812700 | ||||||||
| FaxNumber: | 2604812717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | BIGELOW | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR ENTERPRISE CREDENTIALING & | ||||||||
| AuthorizedOfficialTelephone: | 2602661403 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 261QP2300X | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | 419-0-CMHC | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100463190 C | 05 | IN | MEDICAID | 100463190B | 05 | IN | MEDICAID | 300015906 | 01 | IN | ADDICTION SERVICES | OTHER | 100463190A | 05 | IN | MEDICAID | 300024898 | 01 | IN | ADDICTION SERVICES | OTHER |