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General NPI Number Information
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NPI Number | 1255529335
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Entity Type | Organization
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Legal Business Name | GREATER LAFAYETTE HEALTH SERVICES
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 11/27/2007
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Provider Practice Location Address
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Address Line | 3482 MCCLURE AVE
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City | WEST LAFAYETTE
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State | IN
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Zip | 47906
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Country | US
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Telephone | 765-447-7447
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Fax |
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Provider Business Mailing Address
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Address Line | 3482 MCCLURE AVE
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City | WEST LAFAYETTE
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State | IN
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Zip | 47906
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. TERRANCE E WILSON
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Credential |
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Telephone | 765-423-6161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State | IN
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