Provider Demographics
NPI:1245558808
Name:111 HOME HEALTH CARE AGENCY
Entity type:Organization
Organization Name:111 HOME HEALTH CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:I
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:574-293-6682
Mailing Address - Street 1:336 W GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-2501
Mailing Address - Country:US
Mailing Address - Phone:574-293-6682
Mailing Address - Fax:574-293-7947
Practice Address - Street 1:336 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2501
Practice Address - Country:US
Practice Address - Phone:574-293-6682
Practice Address - Fax:574-293-7947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid