Provider Demographics
NPI:1215669387
Name:KALA D ANDERS
Entity type:Organization
Organization Name:KALA D ANDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:331-442-7815
Mailing Address - Street 1:123 BEIRIGER DR
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-2178
Mailing Address - Country:US
Mailing Address - Phone:331-442-7815
Mailing Address - Fax:
Practice Address - Street 1:5844 ELAINE DR STE 3
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2494
Practice Address - Country:US
Practice Address - Phone:331-442-7815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health