1275614109 NPI number — CROSSROAD - FORT WAYNE CHILDRENS HOME

Table of content: DR. PAUL DOUGLAS DRIGGERS O.D. (NPI 1801085832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275614109 NPI number — CROSSROAD - FORT WAYNE CHILDRENS HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROAD - FORT WAYNE CHILDRENS HOME
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:
1275614109
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:
2525 LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805-5407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-484-4153
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-5407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-4153
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOLLAR
Authorized Official First Name:
JC
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
260-484-4153

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  7342602900837 , 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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