MEDICARE: PAKT, LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1952680001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAKT, LLC

Provider Business Mailing Address
First Line	:	PO BOX 3710
Second Line	:
City	:	WEST LAFAYETTE
State	:	IN
Zip	:	47996-3710
Country	:	US
Telephone Number	:	765-210-0881
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 N 4TH ST
Second Line	:	SUITE 511
City	:	LAFAYETTE
State	:	IN
Zip	:	47901-1371
Country	:	US
Telephone Number	:	765-210-0881
Fax Number	:

Authorized Official
Title or Position	:	AS, MEMBER OF PAKT, LLC
Name	:	GINGER L HUNT-GOINS
Credential	:	MSW, LSW
Telephone Number	:	765-210-0881

Provider Enumeration Date	:	08/08/2011
Last Update Date	:	08/11/2011

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