Basic Information
| Provider Information | |||||||||
| NPI: | 1346520426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINDROSE HEALTH NETWORK, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINDROSE HEALTH NETWORK - HOPE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 TRAFALGAR SQ | ||||||||
| Address2: | |||||||||
| City: | TRAFALGAR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461819515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177394895 | ||||||||
| FaxNumber: | 3178782355 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 BUTNER DR | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472469447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125466000 | ||||||||
| FaxNumber: | 8125460368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2011 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | KOLENDA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3177394895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 200127470C | 05 | IN | MEDICAID |