MEDICARE: SWEET PEAS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	31000165A	IN

General Provider Information

NPI Number	:	1326186966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SWEET PEAS, INC.

Provider Business Mailing Address
First Line	:	10620 CORPORATE DR
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1711
Country	:	US
Telephone Number	:	260-341-8230
Fax Number	:	260-440-8806

Provider Business Practice Location Address
First Line	:	10620 CORPORATE DR
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1711
Country	:	US
Telephone Number	:	260-341-8230
Fax Number	:	260-440-8806

Authorized Official
Title or Position	:	OWNER
Name	:	LISA M. COVILLE
Credential	:	OTR
Telephone Number	:	260-341-8230

Provider Enumeration Date	:	02/04/2007
Last Update Date	:	05/07/2013

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Directions to “SWEET PEAS, INC. ” Practice Location

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