Provider Demographics
NPI:1184922833
Name:KNOX-WINAMAC COMM. HLTH CTRS, INC.
Entity type:Organization
Organization Name:KNOX-WINAMAC COMM. HLTH CTRS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-772-6030
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:121 E. PEACL STREET
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996
Mailing Address - Country:US
Mailing Address - Phone:574-946-6196
Mailing Address - Fax:574-946-7051
Practice Address - Street 1:105 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN PIERRE
Practice Address - State:IN
Practice Address - Zip Code:46374
Practice Address - Country:US
Practice Address - Phone:219-828-3300
Practice Address - Fax:219-828-3500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KNOX-WINAMAC COMMUNITY HEATH CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021497A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100210550AMedicaid
IN100210550AMedicaid