Healthcare Provider Details

I. General information

NPI: 1700393741
Provider Name (Legal Business Name): JEFFREY N DE WESTER TREATMENT AND RESEARCH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6447 S EAST ST STE C
INDIANAPOLIS IN
46227-2119
US

IV. Provider business mailing address

6447 S EAST ST STE C
INDIANAPOLIS IN
46227-2119
US

V. Phone/Fax

Practice location:
  • Phone: 317-735-1851
  • Fax: 317-735-1951
Mailing address:
  • Phone: 317-735-1851
  • Fax: 317-735-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number01036126A
License Number StateIN

VIII. Authorized Official

Name: NATALIE RAE BEMENT
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 317-735-1851