Healthcare Provider Details

I. General information

NPI: 1295301216
Provider Name (Legal Business Name): MAIN STREET HOSPICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HIGHLAND AVE
FRANKLIN IN
46131-1230
US

IV. Provider business mailing address

10 HIGHLAND AVE
FRANKLIN IN
46131-1230
US

V. Phone/Fax

Practice location:
  • Phone: 317-736-0055
  • Fax: 317-739-3505
Mailing address:
  • Phone: 317-736-0055
  • Fax: 317-739-3505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS KEITH WEDDLE
Title or Position: CFO
Credential:
Phone: 317-736-0055