Provider Demographics
NPI:1932485240
Name:MISHAWAKA OSTEOPATHIC CLINIC
Entity Type:Organization
Organization Name:MISHAWAKA OSTEOPATHIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-255-4733
Mailing Address - Street 1:1207 LINCOLNWAY W
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1709
Mailing Address - Country:US
Mailing Address - Phone:574-255-4733
Mailing Address - Fax:
Practice Address - Street 1:1207 LINCOLNWAY W
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1709
Practice Address - Country:US
Practice Address - Phone:574-255-4733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002716A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200520670AMedicaid
INI28154Medicare UPIN