Provider Demographics
NPI:1649361734
Name:SPENCER WELLNESS CENTRE LLC
Entity type:Organization
Organization Name:SPENCER WELLNESS CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP FNP
Authorized Official - Phone:317-852-3616
Mailing Address - Street 1:69 E GARNER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7000
Mailing Address - Country:US
Mailing Address - Phone:317-852-3616
Mailing Address - Fax:317-852-6969
Practice Address - Street 1:69 E GARNER RD STE 300
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-7000
Practice Address - Country:US
Practice Address - Phone:317-852-3616
Practice Address - Fax:317-852-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2004071500239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200522750AMedicaid
IN200522750AMedicaid
DD1621Medicare PIN