Basic Information
| Provider Information | |||||||||
| NPI: | 1902194491 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF HOWARD COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY CARE WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 S LAFOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654538456 | ||||||||
| FaxNumber: | 7654538474 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | RUSSIAVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469799125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654530702 | ||||||||
| FaxNumber: | 7658648711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2011 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7654538456 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 11-005007-1 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.