Provider Demographics
NPI:1235320540
Name:DIABETES ASSOCIATION OF ST JOSEPH COUNTY INC
Entity type:Organization
Organization Name:DIABETES ASSOCIATION OF ST JOSEPH COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAINE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:574-247-6047
Mailing Address - Street 1:6910 NORTH MAIN STREET
Mailing Address - Street 2:BLDG. 9, MAIL UNIT #10
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530
Mailing Address - Country:US
Mailing Address - Phone:574-247-6047
Mailing Address - Fax:547-247-6060
Practice Address - Street 1:6910 NORTH MAIN ST
Practice Address - Street 2:BUILDING 9
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-247-6047
Practice Address - Fax:574-247-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28071850A163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty