Provider Demographics
NPI:1295104669
Name:TRUSTEES OF PURDUE UNIVERSITY
Entity type:Organization
Organization Name:TRUSTEES OF PURDUE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-564-3016
Mailing Address - Street 1:901 PRINCE WILLIAM RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-1758
Mailing Address - Country:US
Mailing Address - Phone:765-564-3016
Mailing Address - Fax:765-564-2608
Practice Address - Street 1:425 E 5TH STREET
Practice Address - Street 2:SUITE B
Practice Address - City:BURLINGTON
Practice Address - State:IN
Practice Address - Zip Code:46915
Practice Address - Country:US
Practice Address - Phone:765-564-3016
Practice Address - Fax:765-564-2608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)