Basic Information
| Provider Information | |||||||||
| NPI: | 1053450536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF WELBORN CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WELBORN CLINIC DME REO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 W STATE ROAD 66 | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476359259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126495061 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3434 W STATE ROAD 66 | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476359259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126495061 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHRISTESON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8124266626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.