Healthcare Provider Details

I. General information

NPI: 1083245955
Provider Name (Legal Business Name): KOSCIUSKO COUNTY FREE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7822 E. EPWORTH FOREST ROAD NORTH WEBSTER UNITED METHODIST CHURCH
NORTH WEBSTER IN
46555
US

IV. Provider business mailing address

22 EMS C27C2 LN
WARSAW IN
46582-9067
US

V. Phone/Fax

Practice location:
  • Phone: 574-834-2871
  • Fax:
Mailing address:
  • Phone: 574-268-1917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHLEEN KOSTRO
Title or Position: PRESIDENT
Credential: MPH
Phone: 574-268-1917