Provider Demographics
NPI:1225584295
Name:PURDUE UNIVERSITY
Entity Type:Organization
Organization Name:PURDUE UNIVERSITY
Other - Org Name:IPFW CENTER FOR HEALTHY LIVING: CAMPUS CLINIC AND WELLNESS PROGRAMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH CLINIC OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CREASIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-481-6967
Mailing Address - Street 1:2101 E COLISEUM BLVD
Mailing Address - Street 2:WU 234
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1445
Mailing Address - Country:US
Mailing Address - Phone:260-481-0400
Mailing Address - Fax:
Practice Address - Street 1:2101 E COLISEUM BLVD
Practice Address - Street 2:WU 234
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1445
Practice Address - Country:US
Practice Address - Phone:260-481-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28079817363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty