Healthcare Provider Details

I. General information

NPI: 1760486393
Provider Name (Legal Business Name): LINCOLN PEDIC CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12311 AUTUMN BREEZE DR
FORT WAYNE IN
46845-9111
US

IV. Provider business mailing address

12311 AUTUMN BREEZE DR
FORT WAYNE IN
46845-9111
US

V. Phone/Fax

Practice location:
  • Phone: 260-637-8414
  • Fax: 260-637-8152
Mailing address:
  • Phone: 260-637-8414
  • Fax: 260-637-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000776A
License Number StateIN

VIII. Authorized Official

Name: MS. JANET ALYCE PAUNWAR
Title or Position: PRESIDENT
Credential:
Phone: 260-637-8414