Organization
180 ENTERPRISE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KIMTOIYA SAM LCAC (OWNER)
(317) 966-7772
Entity
Organization
Contact information
Practice address
3430 CORK BEND DR, INDIANAPOLIS, IN 46239-7669
(317) 966-7772
Mailing address
3430 CORK BEND DR, INDIANAPOLIS, IN 46239-7669
(317) 966-7772
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Enumeration date
12/27/2020
Last updated
12/27/2020
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