Healthcare Provider Details

I. General information

NPI: 1043288111
Provider Name (Legal Business Name): GOSHEN AMBULATORY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 WINSTED DR
GOSHEN IN
46526-4655
US

IV. Provider business mailing address

1605 WINSTED DR
GOSHEN IN
46526-4655
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-8794
  • Fax: 574-534-3082
Mailing address:
  • Phone: 574-534-8794
  • Fax: 574-534-3082

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: DEBORAH STARNES
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 574-534-8794