Provider Demographics
NPI:1477549731
Name:TRUSTEES OF PURDUE UNIVERSITY
Entity Type:Organization
Organization Name:TRUSTEES OF PURDUE UNIVERSITY
Other - Org Name:FAMILY HEALTH CLINIC OF CARROLL COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-564-3016
Mailing Address - Street 1:901 PRINCE WILLIAM RD STE A
Mailing Address - Street 2:
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-1759
Mailing Address - Country:US
Mailing Address - Phone:765-564-3016
Mailing Address - Fax:765-564-2608
Practice Address - Street 1:901 PRINCE WILLIAM RD
Practice Address - Street 2:SUITE A
Practice Address - City:DELPHI
Practice Address - State:IN
Practice Address - Zip Code:46923-1759
Practice Address - Country:US
Practice Address - Phone:765-564-3016
Practice Address - Fax:765-564-2608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURDUE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-22
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200233610AMedicaid
IN15-1863Medicare PIN