Provider Demographics
NPI:1396016473
Name:QUALITY CARE FOR KIDS INDIANA
Entity type:Organization
Organization Name:QUALITY CARE FOR KIDS INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:STIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-226-3937
Mailing Address - Street 1:100 DIAGNOSTIC DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-6524
Mailing Address - Country:US
Mailing Address - Phone:502-226-3937
Mailing Address - Fax:502-226-2929
Practice Address - Street 1:134 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1306
Practice Address - Country:US
Practice Address - Phone:502-226-3937
Practice Address - Fax:502-226-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023950A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01023950AOtherINDIANA LICENSE