Healthcare Provider Details

I. General information

NPI: 1932648839
Provider Name (Legal Business Name): GRETA SLABACH OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SOUTHERN CROSS DR
MIDDLEBURY IN
46540
US

IV. Provider business mailing address

205 SOUTHERN CROSS DR
MIDDLEBURY IN
46540
US

V. Phone/Fax

Practice location:
  • Phone: 574-370-1676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberU1-0001748
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: