Provider Demographics
NPI:1871775254
Name:LA PORTE REGIONAL PHYSICIAN NETWORK
Entity type:Organization
Organization Name:LA PORTE REGIONAL PHYSICIAN NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-325-5485
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:708 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3349
Practice Address - Country:US
Practice Address - Phone:219-324-5335
Practice Address - Fax:219-324-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151020Medicare PIN