Healthcare Provider Details

I. General information

NPI: 1609968254
Provider Name (Legal Business Name): GREATER LAFAYETTE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NORTH 18TH STREET
LAFAYETTE IN
47904
US

IV. Provider business mailing address

1000 NORTH 18TH STREET
LAFAYETTE IN
47904
US

V. Phone/Fax

Practice location:
  • Phone: 765-423-6351
  • Fax:
Mailing address:
  • Phone: 765-423-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number StateIN

VIII. Authorized Official

Name: MR. TERRANCE E WILSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 765-423-6161