Provider Demographics
NPI:1972520997
Name:WELLBOUND OF LAFAYETTE LLC
Entity type:Organization
Organization Name:WELLBOUND OF LAFAYETTE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEL BENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-404-3618
Mailing Address - Street 1:300 SANTANA ROW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2423
Mailing Address - Country:US
Mailing Address - Phone:765-446-1627
Mailing Address - Fax:650-625-6007
Practice Address - Street 1:2 EXECUTIVE DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4878
Practice Address - Country:US
Practice Address - Phone:765-446-1627
Practice Address - Fax:765-449-9475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLBOUND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-16
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200843920AMedicaid
IN200843920AMedicaid