Basic Information
| Provider Information | |||||||||
| NPI: | 1891154076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HORIZON BIOADVANCE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 UNITY PL | ||||||||
| Address2: | SUITE 345 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479055760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654465111 | ||||||||
| FaxNumber: | 7658380972 | ||||||||
| Practice Location | |||||||||
| Address1: | 1345 UNITY PL | ||||||||
| Address2: | SUITE 345 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479055760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654465111 | ||||||||
| FaxNumber: | 7658380972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2016 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | HAMM | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7654465111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 01044990A | IN | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 200173610 | 05 | IN | MEDICAID |