Provider Demographics
NPI:1710422746
Name:DIRECTCLINIC LLC
Entity Type:Organization
Organization Name:DIRECTCLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-212-1900
Mailing Address - Street 1:6435 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 176
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-212-1900
Mailing Address - Fax:
Practice Address - Street 1:7802 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4138
Practice Address - Country:US
Practice Address - Phone:260-466-5671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIRECTCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care