Healthcare Provider Details

I. General information

NPI: 1013234699
Provider Name (Legal Business Name): NAUTILUS HEALTH CARE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SYCAMORE ST
KOKOMO IN
46901-5148
US

IV. Provider business mailing address

PO BOX 645743
CINCINNATI OH
45264-6018
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-5433
  • Fax: 877-496-2102
Mailing address:
  • Phone: 855-689-5105
  • Fax: 877-496-2102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number01059975A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number01059975A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number01059975A
License Number StateIN

VIII. Authorized Official

Name: FRANK WILLIAMS
Title or Position: CEO
Credential:
Phone: 904-446-3519