Healthcare Provider Details

I. General information

NPI: 1619921558
Provider Name (Legal Business Name): KNOX WINAMAC COMMUNITY HEALTH CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S HEATON ST
KNOX IN
46534-2393
US

IV. Provider business mailing address

1520 S HEATON ST
KNOX IN
46534-2393
US

V. Phone/Fax

Practice location:
  • Phone: 574-772-2188
  • Fax: 574-772-2190
Mailing address:
  • Phone: 574-772-2188
  • Fax: 574-772-2190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50000720A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number50000720A
License Number StateIN

VIII. Authorized Official

Name: DIANA R FRITZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 574-772-2188