Provider Demographics
NPI:1720824014
Name:GANDA, RADCLIFFE J V
Entity type:Individual
Prefix:MR
First Name:RADCLIFFE
Middle Name:J V
Last Name:GANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4245 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2409
Mailing Address - Country:US
Mailing Address - Phone:463-248-5072
Mailing Address - Fax:
Practice Address - Street 1:4245 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2409
Practice Address - Country:US
Practice Address - Phone:463-248-5072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103K00000X, 104100000X, 106S00000X, 372600000X, 171M00000X, 172A00000X, 372500000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide