Healthcare Provider Details

I. General information

NPI: 1861034688
Provider Name (Legal Business Name): HEART CITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 CASSOPOLIS STREET
ELKHART IN
46514
US

IV. Provider business mailing address

236 SIMPSON AVENUE
ELKHART IN
46516-4666
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0052
  • Fax: 574-293-3744
Mailing address:
  • Phone: 574-293-0052
  • Fax: 574-293-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ESLEEN E FULTZ
Title or Position: CEO
Credential:
Phone: 574-970-3257