Provider Demographics
NPI:1598111791
Name:TRUSTEES OF PURDUE UNIVERSITY
Entity Type:Organization
Organization Name:TRUSTEES OF PURDUE UNIVERSITY
Other - Org Name:FAMILY HEALTH CLINIC OF WOLCOTT
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
Mailing Address - Street 2:SUITE A
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-1758
Mailing Address - Country:US
Mailing Address - Phone:765-564-3016
Mailing Address - Fax:765-564-2608
Practice Address - Street 1:128 W MARKET ST
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:IN
Practice Address - Zip Code:47995-8130
Practice Address - Country:US
Practice Address - Phone:219-747-2067
Practice Address - Fax:219-747-2068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)