1811413289 NPI number — WASHINGTON TOWNSHIP WELLNESS CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811413289 NPI number — WASHINGTON TOWNSHIP WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON TOWNSHIP WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811413289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8244 E US HIGHWAY 36 STE 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46123-9627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-272-3688
Provider Business Mailing Address Fax Number:
317-272-7515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7203 E US HIGHWAY 36
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46123-7967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-544-6135
Provider Business Practice Location Address Fax Number:
317-544-6139
Provider Enumeration Date:
08/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SMALLWOOD
Authorized Official First Name:
MARIJANE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
317-272-3688

Provider Taxonomy Codes

  • Taxonomy code: 261QC1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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