| |
410 Park Pl Ste A Mishawaka IN 46545-3557 | |
(574) 252-0667 | |
(574) 807-8845 |
Full Name | |
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Speciality | Clinic/center - Multi-specialty |
Location | 410 Park Pl Ste A, Mishawaka, Indiana |
Authorized Official Name and Position | Kevin R Boyer (CHIEF EXECUTIVE OFFICER) |
Authorized Official Contact | 5742963200 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
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410 Park Pl Suite A Mishawaka IN 46545-3557 Ph: (574) 252-0667 | 410 Park Pl Ste A Mishawaka IN 46545-3557 Ph: (574) 252-0667 |
NPI Number | 1851497945 |
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Provider Enumeration Date | 09/15/2006 |
Last Update Date | 05/08/2019 |
Identifier | Type | State | Issuer |
---|---|---|---|
1851497945 | NPI | - | NPPES |
100466600 | Medicaid | IN |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
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