Basic Information
Provider Information
NPI: 1154699346
EntityType: 2
ReplacementNPI:  
OrganizationName: WINDROSE HEALTH NETWORK, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: WINDROSE HEALTH NETWORK - COUNTYLINE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 14 TRAFALGAR SQ
Address2:  
City: TRAFALGAR
State: IN
PostalCode: 461819515
CountryCode: US
TelephoneNumber: 3177394895
FaxNumber: 3178782355
Practice Location
Address1: 8921 SOUTHPOINTE DR
Address2: SUITE A1
City: INDIANAPOLIS
State: IN
PostalCode: 462271084
CountryCode: US
TelephoneNumber: 3178847820
FaxNumber: 3178888851
Other Information
ProviderEnumerationDate: 12/02/2011
LastUpdateDate: 10/09/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ROLLETT
AuthorizedOfficialFirstName: SCOTT
AuthorizedOfficialMiddleName: K
AuthorizedOfficialTitleorPosition: CFO / COO
AuthorizedOfficialTelephone: 3177394895
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QF0400X  Y Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
200127470E05IN MEDICAID


Home