Basic Information
| Provider Information | |||||||||
| NPI: | 1841911591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FC INDIANA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 306414 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372306414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312531110 | ||||||||
| FaxNumber: | 9317229919 | ||||||||
| Practice Location | |||||||||
| Address1: | 2418 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474213049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312531110 | ||||||||
| FaxNumber: | 9317229919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2022 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | CLEMMONS | ||||||||
| AuthorizedOfficialFirstName: | SYDNI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9013511791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.