Healthcare Provider Details

I. General information

NPI: 1013262351
Provider Name (Legal Business Name): WELLNESS GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 LAPORTE AVE PORTER HOSPITAL WOUND CARE CENTER
VALPARAISO IN
46383-5860
US

IV. Provider business mailing address

PO BOX 1296
VALPARAISO IN
46384-1296
US

V. Phone/Fax

Practice location:
  • Phone: 219-263-4600
  • Fax:
Mailing address:
  • Phone: 219-707-5775
  • Fax: 219-707-5775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number02003905B
License Number StateIN

VIII. Authorized Official

Name: DR. JANE BRADLAW
Title or Position: CHAIRMAN
Credential: D.O.
Phone: 219-707-5775