# INDIANA FAIR CHANCE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1235494006
- **Authorized official:** MS. MARY JEAN BULLOCK LSW MBA (MANAGER)
- **Authorized official phone:** (317) 418-7840

## Contact information

- **Practice address:** 7437 COBBLESTONE EAST DR, INDIANAPOLIS, IN 46236-9108
- **Practice address phone:** (317) 418-7840
- **Mailing address:** 7437 COBBLESTONE EAST DR, INDIANAPOLIS, IN 46236-9108
- **Mailing address phone:** (317) 418-7840

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251B00000X | Case Management Agency | — | NULL | Yes |

## Other

- **Enumeration date:** 07/09/2012
- **Last updated:** 07/09/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 201068830 A | WAIVER PROVIDER | IN |