Healthcare Provider Details

I. General information

NPI: 1528000395
Provider Name (Legal Business Name): KNOX-WINAMAC COMMUNITY HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E PEARL ST
WINAMAC IN
46996-1310
US

IV. Provider business mailing address

121 E PEARL ST
WINAMAC IN
46996-1310
US

V. Phone/Fax

Practice location:
  • Phone: 574-946-6196
  • Fax: 574-946-7051
Mailing address:
  • Phone: 574-946-6196
  • Fax: 574-946-7051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01021407A
License Number StateIN

VIII. Authorized Official

Name: TRACEY SHORTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 574-946-6196