Provider Demographics
NPI:1104133511
Name:OPEN DOOR HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:OPEN DOOR HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AYARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-747-2971
Mailing Address - Street 1:PO BOX 1676
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-1676
Mailing Address - Country:US
Mailing Address - Phone:765-286-7000
Mailing Address - Fax:765-213-2769
Practice Address - Street 1:2600 W WHITE RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-5263
Practice Address - Country:US
Practice Address - Phone:765-286-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPEN DOOR HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-07
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200167970Medicaid