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General NPI Number Information
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NPI Number | 1306453626
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Entity Type | Organization
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Legal Business Name | CALVARY ASSEMBLY OF GOD
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Dates
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Enumeration Date | 09/30/2020
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Last Update Date | 02/26/2021
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Provider Practice Location Address
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Address Line | 1317 15TH ST. SE
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City | DEMOTTE
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State | IN
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Zip | 46310-9393
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Country | US
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Telephone | 219-987-4280
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Fax |
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Provider Business Mailing Address
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Address Line | 1317 15TH ST SE
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City | DEMOTTE
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State | IN
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Zip | 46310
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Country | US
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Telephone | 219-987-4280
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES CLARK
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Credential |
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Telephone | 219-987-4280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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