=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245636380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALINDA NIEMAN ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2014
-----------------------------------------------------
Last Update Date | 11/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 E 109TH AVE
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-8693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-662-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 253 S HEATHER LN
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-9148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-765-7850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 360000659A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------