Provider Demographics
NPI:1457558686
Name:FAMILY AND ALTERNATIVE WELLNESS
Entity Type:Organization
Organization Name:FAMILY AND ALTERNATIVE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELORSE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:KRUG
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:765-362-7600
Mailing Address - Street 1:1627 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-2206
Mailing Address - Country:US
Mailing Address - Phone:765-362-4551
Mailing Address - Fax:
Practice Address - Street 1:601 MILL ST
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3440
Practice Address - Country:US
Practice Address - Phone:765-362-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001756A202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200172010Medicaid
ING63691Medicare UPIN
IN200172010Medicaid