NPI 1063397867

Black Clover Holdings LLC

Organisation General Practice Physician Granger, IN

Practice location

Address: 7225 Heritage Square Dr STE 240, Granger, IN 46530-5646
Phone: (574) 369-9102
Mailing address: 54863 Northbridge West CT, Osceola, IN 46561-1309

Authorised official

Name: Joshua M Lederer
Title: Partner
Phone: (574) 369-9102

Registered specialties

General Practice Physician Primary

Allopathic & Osteopathic Physicians Taxonomy 208D00000X

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Registry record

NPI: 1063397867
Entity type: Organization
NPI issued: 11 Aug 2025
Record last updated: 11 Aug 2025

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.