| Organization Name: | BLACKBIRD CLINICAL SERVICES, LLC |
| NPI Number: | 1164669255 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KIMI L. HATHAWAY (PRESIDENT/ CEO) |
| Mailing Address: | 2 Executive Dr Ste D Lafayette |
| State: | IN US |
| Postal Code: | 479054878 |
| Phone Number: | 7654478700 |
| Fax Number: | |
| NPI Enumeration Date: | 01/12/2009 |
| NPI Last Update Date: | 01/12/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 251K00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Agencies |
| Taxonomy Classification: | Public Health or Welfare |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |