1659554277 NPI number — SHANK & WELLS ENTERPRISES, LLC

Table of content: (NPI 1659554277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659554277 NPI number — SHANK & WELLS ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANK & WELLS ENTERPRISES, 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:
Provider Other Organization Name Type Code:
6
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:
1659554277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4536 S CHERRYWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47802-4520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
812-299-8831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2088 S LIBERTY DR
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-5171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-288-2222
Provider Business Practice Location Address Fax Number:
812-288-2387
Provider Enumeration Date:
12/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
KARA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
812-309-1711

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  17001190A , 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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