Provider Demographics
NPI:1679181218
Name:TERRIA CONWELL
Entity Type:Organization
Organization Name:TERRIA CONWELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-628-5672
Mailing Address - Street 1:5835 JESSICA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-1662
Mailing Address - Country:US
Mailing Address - Phone:219-628-5672
Mailing Address - Fax:
Practice Address - Street 1:5835 JESSICA AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-1662
Practice Address - Country:US
Practice Address - Phone:219-628-5672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1699054080Medicaid