1740504315 NPI number — WANEE WALK IN CLINIC LLC

Table of content: (NPI 1740504315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740504315 NPI number — WANEE WALK IN CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WANEE WALK IN CLINIC 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:
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:
1740504315
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 386
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKARUSA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46573-0386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-523-3227
Provider Business Mailing Address Fax Number:
574-296-6522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1028 E WATERFORD ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WAKARUSA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46573-9305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-523-3227
Provider Business Practice Location Address Fax Number:
574-296-6522
Provider Enumeration Date:
03/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HAYES
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHYSICIAN SERVICES
Authorized Official Telephone Number:
574-523-3227

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , with the licence number:  01015929A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X , with the licence number: 01015929A , 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: 200982600A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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