Provider Demographics
NPI:1922438522
Name:INDIANA WELLNESS, LLC
Entity Type:Organization
Organization Name:INDIANA WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-479-1358
Mailing Address - Street 1:1221 S CREASY LN STE K3
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7430
Mailing Address - Country:US
Mailing Address - Phone:765-379-1358
Mailing Address - Fax:765-838-1035
Practice Address - Street 1:1221 S CREASY LN STE K3
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7430
Practice Address - Country:US
Practice Address - Phone:765-379-1358
Practice Address - Fax:765-838-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060426A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty