Basic Information
| Provider Information | |||||||||
| NPI: | 1467483255 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ECHO COMMUNITY HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DIVISION STREET FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477131252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124217489 | ||||||||
| FaxNumber: | 8124360209 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124360205 | ||||||||
| FaxNumber: | 8124360207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | STRADER-MCMILLEN | ||||||||
| AuthorizedOfficialFirstName: | SANDEE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8124217489 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 200079040 | 05 | IN | MEDICAID |