Provider Demographics
NPI:1174662647
Name:BOARD OF TRUSTEES OF WELBORN CLINIC
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF WELBORN CLINIC
Other - Org Name:WELBORN CLINIC DME WESTSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-426-6626
Mailing Address - Street 1:545 S BOEHNE CAMP RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-3703
Mailing Address - Country:US
Mailing Address - Phone:812-429-1818
Mailing Address - Fax:
Practice Address - Street 1:545 S BOEHNE CAMP RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-3703
Practice Address - Country:US
Practice Address - Phone:812-429-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0473400010Medicare NSC