1619561479 NPI number — WABASH VALLEY DERMATOLOGY AND MED SPA INC

Table of content: (NPI 1619561479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619561479 NPI number — WABASH VALLEY DERMATOLOGY AND MED SPA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WABASH VALLEY DERMATOLOGY AND MED SPA 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:
1619561479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18017 N WEAVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62441-4071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-712-9512
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4949 E POPLAR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47803-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-712-9512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
LINDSAY
Authorized Official Middle Name:
SUSAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
217-712-9512

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com