Provider Demographics
NPI:1720777840
Name:AIRWAY & MIDFACE DEVELOPMENT, LLC
Entity type:Organization
Organization Name:AIRWAY & MIDFACE DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSCULP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-968-5166
Mailing Address - Street 1:7221 N FIR RD
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530
Mailing Address - Country:US
Mailing Address - Phone:574-968-5166
Mailing Address - Fax:877-317-3186
Practice Address - Street 1:7221 N FIR RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-968-5166
Practice Address - Fax:877-317-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental