Basic Information
| Provider Information | |||||||||
| NPI: | 1588785653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDSPA WOMAN'S HELATHCARE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 LINCOLNWAY | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193624690 | ||||||||
| FaxNumber: | 2193624692 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 LINCOLNWAY | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193624690 | ||||||||
| FaxNumber: | 2193624692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | JULIUS | ||||||||
| AuthorizedOfficialMiddleName: | RODNEY | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOROWNER | ||||||||
| AuthorizedOfficialTelephone: | 2193624690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01052711A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.