Provider Demographics
NPI:1790854040
Name:EARTHWORKS CENTER INC.
Entity Type:Organization
Organization Name:EARTHWORKS CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:219-794-0029
Mailing Address - Street 1:7725 BROADWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-794-0029
Mailing Address - Fax:219-794-0065
Practice Address - Street 1:7725 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-4731
Practice Address - Country:US
Practice Address - Phone:219-794-0029
Practice Address - Fax:219-794-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001346A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN90000962OtherBLUE CROSS OF ILLINOIS
IN197601OtherATHEM
IN199680Medicare ID - Type Unspecified
IN90000962OtherBLUE CROSS OF ILLINOIS