=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306479043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A.W. HOLDINGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2020
-----------------------------------------------------
Last Update Date | 02/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 OECHSLE RD
-----------------------------------------------------
City | WOODSTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08098-5443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-207-5730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8515 BLUFFTON RD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46809-3022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-207-5730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COMPLIANCE OFFICER
-----------------------------------------------------
Name | NANCY ANN BOBAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 260-207-5604
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------