Healthcare Provider Details

I. General information

NPI: 1932485240
Provider Name (Legal Business Name): MISHAWAKA OSTEOPATHIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 LINCOLNWAY W
MISHAWAKA IN
46544-1709
US

IV. Provider business mailing address

1207 LINCOLNWAY W
MISHAWAKA IN
46544-1709
US

V. Phone/Fax

Practice location:
  • Phone: 574-255-4733
  • Fax:
Mailing address:
  • Phone: 574-255-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02002716A
License Number StateIN

VIII. Authorized Official

Name: DR. LAURA L HELMAN
Title or Position: OWNER
Credential: DO
Phone: 574-255-4733