Basic Information
| Provider Information | |||||||||
| NPI: | 1013262351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLNESS GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE WELLNESS GROUP, P.C. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1296 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463841296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197075775 | ||||||||
| FaxNumber: | 2197075775 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 LAPORTE AVE | ||||||||
| Address2: | PORTER HOSPITAL WOUND CARE CENTER | ||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463835860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192634600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 03/06/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRADLAW | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 2197075775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 02003905B | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
No ID Information.