Provider Demographics
NPI:1942483896
Name:GREENCASTLE WOUND & DIABETIC FOOT CARE CLINIC, LLC
Entity Type:Organization
Organization Name:GREENCASTLE WOUND & DIABETIC FOOT CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTALILLA-QUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:765-720-7085
Mailing Address - Street 1:305 MEDIC WAY
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-2296
Mailing Address - Country:US
Mailing Address - Phone:765-720-7085
Mailing Address - Fax:
Practice Address - Street 1:305 MEDIC WAY
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2296
Practice Address - Country:US
Practice Address - Phone:765-720-7085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002412A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN254640Medicare PIN