Provider Demographics
NPI:1396250502
Name:DIRECTCLINIC LLC
Entity type:Organization
Organization Name:DIRECTCLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-212-1900
Mailing Address - Street 1:1355 GETZ ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1609
Mailing Address - Country:US
Mailing Address - Phone:260-212-1900
Mailing Address - Fax:260-222-2827
Practice Address - Street 1:1355 GETZ ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1609
Practice Address - Country:US
Practice Address - Phone:260-212-1900
Practice Address - Fax:260-222-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care