Provider Demographics
NPI:1306897004
Name:PARK CENTER INC
Entity type:Organization
Organization Name:PARK CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR ENTERPRISE CREDENTIALING &
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BIGELOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-266-1403
Mailing Address - Street 1:11109 PARKVIEW PLAZA DRIVE
Mailing Address - Street 2:MAILBOX 117
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3404
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:260-481-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X, 261QR0405X
IN261QP2300X
IN419-0-CMHC261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100463190 CMedicaid
IN100463190BMedicaid
IN300015906OtherADDICTION SERVICES
IN100463190AMedicaid
IN300024898OtherADDICTION SERVICES