Healthcare Provider Details

I. General information

NPI: 1902269889
Provider Name (Legal Business Name): COMMUNITY OCCUPATIONAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22818 OLD US 20
ELKHART IN
46516-9150
US

IV. Provider business mailing address

22818 OLD US 20
ELKHART IN
46516-9150
US

V. Phone/Fax

Practice location:
  • Phone: 574-389-1231
  • Fax: 574-389-1232
Mailing address:
  • Phone: 574-389-1231
  • Fax: 574-389-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number28193462A
License Number StateIN

VIII. Authorized Official

Name: AIMEE WEISS
Title or Position: PRACTICE MANAGER
Credential: RT
Phone: 574-389-1231