Healthcare Provider Details

I. General information

NPI: 1790809788
Provider Name (Legal Business Name): ROCCWELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 UNITY PL SUITE A
LAFAYETTE IN
47905-5793
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-2450
  • Fax: 765-446-1083
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-446-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: MARTHA K MILLER
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 765-446-5417