Healthcare Provider Details

I. General information

NPI: 1134518053
Provider Name (Legal Business Name): DELAINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 COUNTRY CLUB RD SUITE C
VALPARAISO IN
46383-2251
US

IV. Provider business mailing address

1620 COUNTRY CLUB RD SUITE C
VALPARAISO IN
46383-2251
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-7546
  • Fax: 866-467-3763
Mailing address:
  • Phone: 219-464-7546
  • Fax: 866-467-3763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01039408A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01039408A
License Number StateIN

VIII. Authorized Official

Name: DOUGLAS J VAN PUTTEN
Title or Position: OWNER/CEO
Credential: MD
Phone: 219-464-7546