Provider Demographics
NPI:1124166194
Name:BOARD OF TRUSTEES OF WELBORN CLINIC
Entity type:Organization
Organization Name:BOARD OF TRUSTEES OF WELBORN CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHRISTESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-426-9228
Mailing Address - Street 1:3434 W STATE ROAD 66
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47635-9259
Mailing Address - Country:US
Mailing Address - Phone:812-649-5061
Mailing Address - Fax:
Practice Address - Street 1:3434 W STATE ROAD 66
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-9259
Practice Address - Country:US
Practice Address - Phone:812-649-5061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty