=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649422668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FT. WAYNE-ALLEN COUNTY DEPARTMENT OF HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2008
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4813 NEW HAVEN AVE
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46803-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-449-7578
-----------------------------------------------------
Fax | 260-427-1391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 E BERRY ST. SUITE 360
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46802-2738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-449-7578
-----------------------------------------------------
Fax | 260-427-1391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEPARTMENT ADMINISTRATOR
-----------------------------------------------------
Name | MRS. MINDY WALDRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 260-449-7578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 01041980A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------