Healthcare Provider Details

I. General information

NPI: 1245558808
Provider Name (Legal Business Name): 111 HOME HEALTH CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 W GARFIELD AVE
ELKHART IN
46516-2501
US

IV. Provider business mailing address

336 W GARFIELD AVE
ELKHART IN
46516-2501
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-6682
  • Fax: 574-293-7947
Mailing address:
  • Phone: 574-293-6682
  • Fax: 574-293-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAVERN I SUGGS
Title or Position: CEO
Credential: LPN
Phone: 574-293-6682