Provider Demographics
NPI:1851498075
Name:GREATER LAFAYETTE HEALTH SERVICES
Entity Type:Organization
Organization Name:GREATER LAFAYETTE HEALTH SERVICES
Other - Org Name:CLINTON COUNTY DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-423-6161
Mailing Address - Street 1:1300 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3313
Mailing Address - Country:US
Mailing Address - Phone:765-659-2575
Mailing Address - Fax:
Practice Address - Street 1:1300 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3313
Practice Address - Country:US
Practice Address - Phone:765-659-2575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN153509Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER