Provider Demographics
NPI:1174026363
Name:DEACONESS CLINIC, INC
Entity Type:Organization
Organization Name:DEACONESS CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:WATHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-450-3296
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-641-0088
Mailing Address - Fax:812-641-0092
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-1591
Practice Address - Country:US
Practice Address - Phone:812-641-0088
Practice Address - Fax:812-641-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center