Organization
INDIANA FAIR CHANCE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MARY JEAN BULLOCK LSW MBA (MANAGER)
(317) 418-7840
Entity
Organization
Contact information
Practice address
7437 COBBLESTONE EAST DR, INDIANAPOLIS, IN 46236-9108
(317) 418-7840
Mailing address
7437 COBBLESTONE EAST DR, INDIANAPOLIS, IN 46236-9108
(317) 418-7840
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
201068830 A
WAIVER PROVIDER
IN
Enumeration date
07/09/2012
Last updated
07/09/2012
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