Healthcare Provider Details

I. General information

NPI: 1568568947
Provider Name (Legal Business Name): LAKEVIEW WESLEYAN CHURCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 S WESTERN AVE
MARION IN
46953-5778
US

IV. Provider business mailing address

5230 S WESTERN AVE
MARION IN
46953-5778
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-2208
  • Fax: 765-674-3273
Mailing address:
  • Phone: 765-674-2208
  • Fax: 765-674-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIN

VIII. Authorized Official

Name: APRIL D LEACH
Title or Position: OFFICIAL DELEGATE
Credential:
Phone: 765-674-2208