=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629476890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMPTSERVE FAMILY MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2014
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 MORTON AVE
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46151-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-352-8082
-----------------------------------------------------
Fax | 765-352-8082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 MORTON AVE
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46151-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-352-8082
-----------------------------------------------------
Fax | 765-352-8082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MR. ROBERT WALLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-352-8082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71004944B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------