Healthcare Provider Details

I. General information

NPI: 1043513294
Provider Name (Legal Business Name): MEDICCI KLINX INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 LINCOLNWAY STE C
VALPARAISO IN
46383-5852
US

IV. Provider business mailing address

1608 LINCOLNWAY STE C
VALPARAISO IN
46383-5852
US

V. Phone/Fax

Practice location:
  • Phone: 219-299-2075
  • Fax:
Mailing address:
  • Phone: 219-299-2075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01068033A
License Number StateIN

VIII. Authorized Official

Name: DR. OMAR VILLARROEL
Title or Position: PRESIDENT
Credential: MD
Phone: 912-658-1155