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1007 Lincolnway La Porte IN 46350-3201 | |
| (219) 326-2489 | |
| (219) 326-2584 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Multi-specialty |
| Location | 1007 Lincolnway, La Porte, Indiana |
| Authorized Official Name and Position | Brian Donnelly (VP OF STRATEGY & AMBULATORY SERVICE) |
| Authorized Official Contact | 2193254682 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 1690 La Porte IN 46352-1690 Ph: (219) 326-2312 | 1007 Lincolnway La Porte IN 46350-3201 Ph: (219) 326-2489 |
| NPI Number | 1760593776 |
|---|---|
| Provider Enumeration Date | 08/31/2006 |
| Last Update Date | 05/22/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760593776 | NPI | - | NPPES |
| 200255890 | Medicaid | IN | |
| 100165070 | Medicaid | IN | |
| 200988350 | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
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