Provider Demographics
NPI:1215960463
Name:KEENER CIVIL TOWNSHIP JASPER COUNTY TTEE
Entity type:Organization
Organization Name:KEENER CIVIL TOWNSHIP JASPER COUNTY TTEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:KEENER TOWNSHIP TRUSTEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HABERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-987-7825
Mailing Address - Street 1:16900 N US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8369
Mailing Address - Country:US
Mailing Address - Phone:219-987-7825
Mailing Address - Fax:219-987-7826
Practice Address - Street 1:708 15TH ST SE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310
Practice Address - Country:US
Practice Address - Phone:219-987-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00343416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20024750Medicaid
IN000000191760OtherATHEM
IN987100Medicare ID - Type UnspecifiedMEDICARE ID #