Provider Demographics
NPI:1639364946
Name:WOODLAND WELLNESS AND REHABILITATION
Entity Type:Organization
Organization Name:WOODLAND WELLNESS AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:DOLEZAL-REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-872-2933
Mailing Address - Street 1:8865 W 400 N
Mailing Address - Street 2:SUITE 122
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9222
Mailing Address - Country:US
Mailing Address - Phone:219-872-2933
Mailing Address - Fax:219-872-2934
Practice Address - Street 1:8865 W 400 N
Practice Address - Street 2:SUITE 122
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9222
Practice Address - Country:US
Practice Address - Phone:219-872-2933
Practice Address - Fax:219-872-2934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003416A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy