Healthcare Provider Details

I. General information

NPI: 1740531409
Provider Name (Legal Business Name): LAFAYETTE'S WOUND CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 S EARL AVE SUITE B
LAFAYETTE IN
47904-3603
US

IV. Provider business mailing address

635 S EARL AVE SUITE B
LAFAYETTE IN
47904-3603
US

V. Phone/Fax

Practice location:
  • Phone: 765-838-8208
  • Fax: 765-838-8207
Mailing address:
  • Phone: 765-838-8208
  • Fax: 765-838-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLEY HUIZAR
Title or Position: CEO
Credential: DPT
Phone: 765-838-1660