Healthcare Provider Details

I. General information

NPI: 1538227053
Provider Name (Legal Business Name): KOSCIUSKO COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MED PARK DR STE B
WARSAW IN
46580-3285
US

IV. Provider business mailing address

1000 MED PARK DR STE B
WARSAW IN
46580-3285
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-7028
  • Fax: 574-267-8417
Mailing address:
  • Phone: 574-267-7028
  • Fax: 574-267-8417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateIN

VIII. Authorized Official

Name: MR. ROBERT C WEAVER
Title or Position: DIRECTOR
Credential:
Phone: 574-372-2349