Facts
- Status
- A
- Credential
- MS, ATC
- Type
- Individual
- Enumeration date
- 2019-08-05
- Last updated
- 2019-08-05
Licenses
- License IN
- 36002014A
Location
- Practice location
- 405 E 9TH ST
- City
- LAPEL IN
- Postal code
- 460519635
- Phone
- 765-621-5637
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.