Provider Demographics
NPI:1083245955
Name:KOSCIUSKO COUNTY FREE CLINIC, INC
Entity Type:Organization
Organization Name:KOSCIUSKO COUNTY FREE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTRO
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:574-268-1917
Mailing Address - Street 1:22 EMS C27C2 LN
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-9067
Mailing Address - Country:US
Mailing Address - Phone:574-268-1917
Mailing Address - Fax:
Practice Address - Street 1:7822 E. EPWORTH FOREST ROAD
Practice Address - Street 2:NORTH WEBSTER UNITED METHODIST CHURCH
Practice Address - City:NORTH WEBSTER
Practice Address - State:IN
Practice Address - Zip Code:46555
Practice Address - Country:US
Practice Address - Phone:574-834-2871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service