Healthcare Provider Details

I. General information

NPI: 1184922833
Provider Name (Legal Business Name): KNOX-WINAMAC COMM. HLTH CTRS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N. BROADWAY
SAN PIERRE IN
46374
US

IV. Provider business mailing address

PO BOX 338 121 E. PEACL STREET
WINAMAC IN
46996
US

V. Phone/Fax

Practice location:
  • Phone: 219-828-3300
  • Fax: 219-828-3500
Mailing address:
  • Phone: 574-946-6196
  • Fax: 574-946-7051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01021497A
License Number StateIN

VIII. Authorized Official

Name: TRACEY SHORTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 574-772-6030