Healthcare Provider Details

I. General information

NPI: 1497273494
Provider Name (Legal Business Name): SQUAREONE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5422 N KEYSTONE AVE
INDIANAPOLIS IN
46220
US

IV. Provider business mailing address

5422 N KEYSTONE AVE
INDIANAPOLIS IN
46220-3456
US

V. Phone/Fax

Practice location:
  • Phone: 317-698-7274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NORMAN WILLIAMS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 317-698-7274