Provider Demographics
NPI:1174082523
Name:UPSTREAM HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:UPSTREAM HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-763-3636
Mailing Address - Street 1:3207 WILLOWCREEK RD STE A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5013
Mailing Address - Country:US
Mailing Address - Phone:219-763-3636
Mailing Address - Fax:219-764-2479
Practice Address - Street 1:3207 WILLOWCREEK RD STE A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5013
Practice Address - Country:US
Practice Address - Phone:219-763-3636
Practice Address - Fax:219-764-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty