Provider Demographics
NPI:1962828293
Name:COMMUNITY HEALTH & WELLNESS PARTNERS OF LOGAN COUNTY
Entity Type:Organization
Organization Name:COMMUNITY HEALTH & WELLNESS PARTNERS OF LOGAN COUNTY
Other - Org Name:INDIAN LAKE COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-887-1013
Mailing Address - Street 1:4879 ST. RT. 68 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357
Mailing Address - Country:US
Mailing Address - Phone:937-599-1411
Mailing Address - Fax:
Practice Address - Street 1:8200 STATE ROUTE 366
Practice Address - Street 2:SUITE NO. 1
Practice Address - City:RUSSELLS POINT
Practice Address - State:OH
Practice Address - Zip Code:43348-9670
Practice Address - Country:US
Practice Address - Phone:937-599-1411
Practice Address - Fax:937-599-4128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH & WELLNESS PARTNERS OF LOGAN COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-11
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH361046Medicare Oscar/Certification