Provider Demographics
NPI:1447596317
Name:WELLNESS CENTER OF INDIANA LLC
Entity Type:Organization
Organization Name:WELLNESS CENTER OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:G
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:812-683-2215
Mailing Address - Street 1:1706 MEDICAL ARTS DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-9049
Mailing Address - Country:US
Mailing Address - Phone:812-683-2215
Mailing Address - Fax:812-683-2064
Practice Address - Street 1:1706 MEDICAL ARTS DR
Practice Address - Street 2:SUITE 6
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-9049
Practice Address - Country:US
Practice Address - Phone:812-683-2215
Practice Address - Fax:812-683-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-21
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000658A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU30509Medicare UPIN