Provider Demographics
NPI:1669424784
Name:CAYLOR NICKEL CLINIC, PC
Entity type:Organization
Organization Name:CAYLOR NICKEL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HUMAN RESOURCES
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUMGARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-919-3302
Mailing Address - Street 1:1 CAYLOR NICKEL SQ
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-2529
Mailing Address - Country:US
Mailing Address - Phone:260-919-3302
Mailing Address - Fax:260-919-3551
Practice Address - Street 1:1 CAYLOR NICKEL SQ
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-2529
Practice Address - Country:US
Practice Address - Phone:260-919-3302
Practice Address - Fax:260-919-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200383890Medicaid
IN100449040AMedicaid
IN200383890Medicaid
IN912560Medicare PIN
IN911080Medicare PIN
IN100449040AMedicaid
IN912030Medicare PIN
IN0389500001Medicare NSC