Healthcare Provider Details

I. General information

NPI: 1790217081
Provider Name (Legal Business Name): MACGASGIRL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7747 W JEFFERSON BLVD STE B
FORT WAYNE IN
46804-4135
US

IV. Provider business mailing address

PO BOX 1296
WARSAW IN
46581-1296
US

V. Phone/Fax

Practice location:
  • Phone: 260-434-9104
  • Fax:
Mailing address:
  • Phone: 574-268-9640
  • Fax: 574-268-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28147521A
License Number StateIN

VIII. Authorized Official

Name: LAURA R MEANEY
Title or Position: OWNER
Credential: CRNA
Phone: 574-268-9640