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General NPI Number Information
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NPI Number | 1801575972
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Entity Type | Organization
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Legal Business Name | ASTRUM WELLNESS AND RECOVERY LLC
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Dates
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Enumeration Date | 07/14/2023
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Last Update Date | 07/14/2023
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Provider Practice Location Address
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Address Line | 129 E DEWALD ST
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City | FORT WAYNE
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State | IN
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Zip | 46803-3317
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Country | US
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Telephone | 260-280-3341
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Fax |
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Provider Business Mailing Address
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Address Line | 2712 N WELLS ST
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City | FORT WAYNE
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State | IN
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Zip | 46808-2102
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Country | US
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Telephone | 317-608-7856
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Fax |
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Authorized Official
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Title or Position | CO DIRECTOR
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Name | KIMBERLY LATIBEAUDIER
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Credential |
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Telephone | 260-280-3341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number |
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License Number State |
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