Healthcare Provider Details

I. General information

NPI: 1427262492
Provider Name (Legal Business Name): CASS COUNTY WIC PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 DIVIDEND DR
LOGANSPORT IN
46947-1572
US

IV. Provider business mailing address

8003 CASTLEWAY DRIVE
INDIANAPOLIS IN
46250
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-4961
  • Fax: 574-735-0429
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-576-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LYNN H. CLOTHIER
Title or Position: CEO
Credential:
Phone: 317-576-1335