Provider Demographics
NPI:1043513294
Name:MEDICCI KLINX INC.
Entity type:Organization
Organization Name:MEDICCI KLINX INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARROEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-658-1155
Mailing Address - Street 1:1608 LINCOLNWAY STE C
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5852
Mailing Address - Country:US
Mailing Address - Phone:219-299-2075
Mailing Address - Fax:
Practice Address - Street 1:1608 LINCOLNWAY STE C
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5852
Practice Address - Country:US
Practice Address - Phone:219-299-2075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068033A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty