=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962914119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLE WOMAN'S HEALTH ALLIANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2017
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 LINCOLN WAY W
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46628-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-835-6858
-----------------------------------------------------
Fax | 888-724-3239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 E MARKET ST STE 200
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22902-5381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-202-8818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | VIRGINIA E SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-422-2061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------