MEDICARE: PEACE OF MIND IN HOME CARE, 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	253Z00000X	In Home Supportive Care Agency	13-013206-1	IN

General Provider Information

NPI Number	:	1972930931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACE OF MIND IN HOME CARE, LLC

Provider Business Mailing Address
First Line	:	1627 N WELLS ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3281
Country	:	US
Telephone Number	:	260-498-2360
Fax Number	:

Provider Business Practice Location Address
First Line	:	1627 N WELLS ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3281
Country	:	US
Telephone Number	:	260-498-2360
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. JOHN GREG KING
Credential	:	CSCM
Telephone Number	:	260-498-2360

Provider Enumeration Date	:	10/04/2013
Last Update Date	:	10/04/2013

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