Provider Demographics
NPI:1740504315
Name:WANEE WALK IN CLINIC LLC
Entity type:Organization
Organization Name:WANEE WALK IN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-523-3227
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-0386
Mailing Address - Country:US
Mailing Address - Phone:574-523-3227
Mailing Address - Fax:574-296-6522
Practice Address - Street 1:1028 E WATERFORD ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAKARUSA
Practice Address - State:IN
Practice Address - Zip Code:46573-9305
Practice Address - Country:US
Practice Address - Phone:574-523-3227
Practice Address - Fax:574-296-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01015929A261QC1500X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200982600AMedicaid
INM100017346Medicare PIN
INDQ5896Medicare PIN