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General NPI Number Information
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NPI Number | 1639218910
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Entity Type | Organization
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Legal Business Name | 21ST CENTURY TOTAL WELLNESS
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Dates
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Enumeration Date | 02/05/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 501 W 84TH DR STE 1
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City | MERRILLVILLE
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State | IN
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Zip | 46410-7013
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Country | US
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Telephone | 219-756-4695
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Fax | 219-793-9629
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Provider Business Mailing Address
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Address Line | 501 W 84TH DR STE 1
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City | MERRILLVILLE
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State | IN
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Zip | 46410-7013
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Country | US
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Telephone | 219-756-4695
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Fax | 219-793-9629
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Authorized Official
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Title or Position | PRESIDENT
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Name | EDGAR D PRATER
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Credential |
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Telephone | 219-756-4695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 32000255A
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License Number State | IN
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