Healthcare Provider Details

I. General information

NPI: 1134329477
Provider Name (Legal Business Name): YESSENOW CENTRE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 COLUMBIA AVE SUITE A-2
MUNSTER IN
46321-3538
US

IV. Provider business mailing address

9250 COLUMBIA AVE SUITE A-2
MUNSTER IN
46321-3538
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-8136
  • Fax: 219-836-8135
Mailing address:
  • Phone: 219-836-8136
  • Fax: 219-836-8135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01039206A
License Number StateIN

VIII. Authorized Official

Name: MS. VALORIE PECK
Title or Position: OFFICE MANAGER
Credential:
Phone: 219-836-8136