Basic Information
| Provider Information | |||||||||
| NPI: | 1942483896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENCASTLE WOUND & DIABETIC FOOT CARE CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 MEDIC WAY | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461352296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657207085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 305 MEDIC WAY | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461352296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657207085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2007 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | ESTALILLA-QUIZ | ||||||||
| AuthorizedOfficialFirstName: | AMELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7657207085 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 71002412A | IN | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.