1235320540 NPI number — DIABETES ASSOCIATION OF ST JOSEPH COUNTY INC

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 1235320540 NPI number — DIABETES ASSOCIATION OF ST JOSEPH COUNTY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES ASSOCIATION OF ST JOSEPH COUNTY INC
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:
1235320540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6910 NORTH MAIN STREET
Provider Second Line Business Mailing Address:
BLDG. 9, MAIL UNIT #10
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-247-6047
Provider Business Mailing Address Fax Number:
547-247-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6910 NORTH MAIN ST
Provider Second Line Business Practice Location Address:
BUILDING 9
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-247-6047
Provider Business Practice Location Address Fax Number:
574-247-6060
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAINE
Authorized Official First Name:
BONITA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
574-247-6047

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , with the licence number:  28071850A , 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)





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