Healthcare Provider Details

I. General information

NPI: 1790021194
Provider Name (Legal Business Name): PRINCETON CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N HART ST
PRINCETON IN
47670-1532
US

IV. Provider business mailing address

PO BOX 3276
EVANSVILLE IN
47731-3276
US

V. Phone/Fax

Practice location:
  • Phone: 812-385-5820
  • Fax: 812-385-5826
Mailing address:
  • Phone: 812-473-0181
  • Fax: 812-473-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name: KYLE G JOHNSON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 812-385-8306