Provider Demographics
NPI:1629885280
Name:PREMIUM CAREGIVER SUPPORTS LLC
Entity type:Organization
Organization Name:PREMIUM CAREGIVER SUPPORTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:317-675-0088
Mailing Address - Street 1:2345 MUNN CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-1479
Mailing Address - Country:US
Mailing Address - Phone:317-675-0088
Mailing Address - Fax:
Practice Address - Street 1:2345 MUNN CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-1479
Practice Address - Country:US
Practice Address - Phone:317-675-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities