Healthcare Provider Details

I. General information

NPI: 1639218910
Provider Name (Legal Business Name): 21ST CENTURY TOTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W 84TH DR STE 1
MERRILLVILLE IN
46410-7013
US

IV. Provider business mailing address

501 W 84TH DR STE 1
MERRILLVILLE IN
46410-7013
US

V. Phone/Fax

Practice location:
  • Phone: 219-756-4695
  • Fax: 219-793-9629
Mailing address:
  • Phone: 219-756-4695
  • Fax: 219-793-9629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32000255A
License Number StateIN

VIII. Authorized Official

Name: EDGAR D PRATER
Title or Position: PRESIDENT
Credential:
Phone: 219-756-4695