| |
410 Park Pl Suite B Mishawaka IN 46545-3557 | |
(574) 855-5800 | |
(574) 855-5805 |
Full Name | |
---|---|
Speciality | Clinic/center - Multi-specialty |
Location | 410 Park Pl, Mishawaka, Indiana |
Authorized Official Name and Position | Timothy Porsche (MANAGING PARTNER) |
Authorized Official Contact | 5742963200 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
Po Box 2968 Elkhart IN 46515-2968 Ph: (574) 296-3200 | 410 Park Pl Suite B Mishawaka IN 46545-3557 Ph: (574) 855-5800 |
NPI Number | 1235303165 |
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Provider Enumeration Date | 04/22/2008 |
Last Update Date | 07/15/2020 |
Identifier | Type | State | Issuer |
---|---|---|---|
1235303165 | NPI | - | NPPES |
100466600D | Medicaid | IN | |
0359310002 | Other | IN | MEDICARE NSC |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
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