Healthcare Provider Details

I. General information

NPI: 1740504315
Provider Name (Legal Business Name): WANEE WALK IN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 E WATERFORD ST SUITE A
WAKARUSA IN
46573-9305
US

IV. Provider business mailing address

PO BOX 386
WAKARUSA IN
46573-0386
US

V. Phone/Fax

Practice location:
  • Phone: 574-523-3227
  • Fax: 574-296-6522
Mailing address:
  • Phone: 574-523-3227
  • Fax: 574-296-6522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number01015929A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number01015929A
License Number StateIN

VIII. Authorized Official

Name: MS. CINDY HAYES
Title or Position: DIRECTOR OF PHYSICIAN SERVICES
Credential:
Phone: 574-523-3227