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General NPI Number Information
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NPI Number | 1922438522
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Entity Type | Organization
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Legal Business Name | INDIANA WELLNESS, LLC
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Dates
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Enumeration Date | 11/18/2013
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Last Update Date | 11/18/2013
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Provider Practice Location Address
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Address Line | 1221 S CREASY LN STE K3
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City | LAFAYETTE
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State | IN
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Zip | 47905-7430
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Country | US
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Telephone | 765-379-1358
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Fax | 765-838-1035
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Provider Business Mailing Address
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Address Line | 1221 S CREASY LN STE K3
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City | LAFAYETTE
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State | IN
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Zip | 47905-7430
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Country | US
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Telephone | 765-379-1358
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Fax | 765-838-1035
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | DOUGLAS MENNEN
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Credential |
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Telephone | 765-479-1358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 01060426A
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License Number State | IN
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