1972520997 NPI number — WELLBOUND OF LAFAYETTE LLC

Table of content: (NPI 1972520997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972520997 NPI number — WELLBOUND OF LAFAYETTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLBOUND OF LAFAYETTE LLC
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:
WELLBOUND OF LAFAYETTE
Provider Other Organization Name Type Code:
3
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:
1972520997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SANTANA ROW
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95128-2423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-446-1627
Provider Business Mailing Address Fax Number:
650-625-6007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-4878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-446-1627
Provider Business Practice Location Address Fax Number:
765-449-9475
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEL BENE
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SECRETARY/CFO
Authorized Official Telephone Number:
650-404-3618

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200843920A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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