Healthcare Provider Details

I. General information

NPI: 1053600411
Provider Name (Legal Business Name): A.W. HOLDINGS OF MARYLAND, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8515 BLUFFTON RD
FORT WAYNE IN
46809-3022
US

IV. Provider business mailing address

8515 BLUFFTON RD
FORT WAYNE IN
46809-3022
US

V. Phone/Fax

Practice location:
  • Phone: 260-744-6145
  • Fax: 260-444-0006
Mailing address:
  • Phone: 260-744-6145
  • Fax: 260-444-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM J SWISS
Title or Position: PRESIDENT
Credential:
Phone: 260-744-6145