1861606865 NPI number — CLINTON COUNTY WIC PROGRAM

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 1861606865 NPI number — CLINTON COUNTY WIC PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON COUNTY WIC PROGRAM
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:
1861606865
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:
8003 CASTLEWAY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-576-1335
Provider Business Mailing Address Fax Number:
317-576-1339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CLINTON COUNTY WIC PROGRAM
Provider Second Line Business Practice Location Address:
2120 WASHINGTON AVENUE
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-659-2131
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLOTHIER
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
317-576-1335

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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