Provider Demographics
NPI:1336319649
Name:CBC, L.L.C.
Entity Type:Organization
Organization Name:CBC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:YESSENOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-756-0600
Mailing Address - Street 1:5355 COMMERCE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-5325
Mailing Address - Country:US
Mailing Address - Phone:219-756-0600
Mailing Address - Fax:219-756-0608
Practice Address - Street 1:5355 COMMERCE BOULEVARD
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5325
Practice Address - Country:US
Practice Address - Phone:219-756-0600
Practice Address - Fax:219-756-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN080107642261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000566567OtherANTHEM