Healthcare Provider Details

I. General information

NPI: 1689714727
Provider Name (Legal Business Name): FORT WAYNE ALLERGY AND ASTHMA CONSULTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7920 W JEFFERSON BLVD SUITE 220
FORT WAYNE IN
46804-4168
US

IV. Provider business mailing address

7920 W JEFFERSON BLVD SUITE 220
FORT WAYNE IN
46804-4168
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-5670
  • Fax:
Mailing address:
  • Phone: 260-436-5670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: LYN WITTWER
Title or Position: OFFICE MANAGER
Credential:
Phone: 260-436-5670