Basic Information
| Provider Information | |||||||||
| NPI: | 1184292054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIKING PSYCHIATRY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6336 CONSTITUTION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602021060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6336 CONSTITUTION DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602021060 | ||||||||
| FaxNumber: | 2608001512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2021 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | GODDARD | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8126975244 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.