1073510244 NPI number — BROADWAY FOOT CLINIC CORPORATION

Table of content: ERIKA DANA NIEWALD LAC. (NPI 1093436735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073510244 NPI number — BROADWAY FOOT CLINIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY FOOT CLINIC CORPORATION
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:
1073510244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3290 GRANT ST
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
GARY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46408-1015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-884-7880
Provider Business Mailing Address Fax Number:
219-884-7880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3290 GRANT ST
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46408-1015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-884-7880
Provider Business Practice Location Address Fax Number:
219-884-7880
Provider Enumeration Date:
07/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OJIKUTU
Authorized Official First Name:
SONNY
Authorized Official Middle Name:
O
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
219-884-7880

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  07000445A , 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: 10058560 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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