Healthcare Provider Details

I. General information

NPI: 1558361592
Provider Name (Legal Business Name): FAMILY LIFE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W 10TH ST SUITE 101
HOBART IN
46342-5990
US

IV. Provider business mailing address

111 W 10TH ST SUITE 101
HOBART IN
46342-5990
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-0797
  • Fax: 219-942-6243
Mailing address:
  • Phone: 219-947-0797
  • Fax: 219-942-6243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01050865A
License Number StateIN

VIII. Authorized Official

Name: PAULA BAKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 219-947-0797