Healthcare Provider Details

I. General information

NPI: 1588640353
Provider Name (Legal Business Name): ENT REALTY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 W JEFFERSON BLVD SUITE 102
FORT WAYNE IN
46804-4128
US

IV. Provider business mailing address

10021 DUPONT CIRCLE CT
FORT WAYNE IN
46825-1604
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-4368
  • Fax: 260-436-6283
Mailing address:
  • Phone: 260-426-8117
  • Fax: 260-420-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HOLLY THOMPSON
Title or Position: CEO
Credential:
Phone: 260-207-1675