Healthcare Provider Details

I. General information

NPI: 1942135413
Provider Name (Legal Business Name): DERRICK LAMONTE WINSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W MARION ST # 1A
SOUTH BEND IN
46601-1162
US

IV. Provider business mailing address

406 W MARION ST # 1A
SOUTH BEND IN
46601-1162
US

V. Phone/Fax

Practice location:
  • Phone: 574-229-2153
  • Fax:
Mailing address:
  • Phone: 574-229-2153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: