Provider Demographics
NPI:1659555142
Name:CLAY TOWNSHIP CLINIC LLC
Entity Type:Organization
Organization Name:CLAY TOWNSHIP CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:EICHORST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-272-7500
Mailing Address - Street 1:50795 INDIANA STATE ROUTE 933
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-2050
Mailing Address - Country:US
Mailing Address - Phone:574-272-7500
Mailing Address - Fax:574-272-2291
Practice Address - Street 1:50795 INDIANA STATE ROUTE 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-2050
Practice Address - Country:US
Practice Address - Phone:574-272-7500
Practice Address - Fax:574-272-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN144310Medicare PIN