Healthcare Provider Details

I. General information

NPI: 1588840219
Provider Name (Legal Business Name): AMY KENDALL DBA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52160 FIELDSTONE LN
GRANGER IN
46530-9266
US

IV. Provider business mailing address

PO BOX 410
GRANGER IN
46530-0410
US

V. Phone/Fax

Practice location:
  • Phone: 574-315-3351
  • Fax: 574-272-1935
Mailing address:
  • Phone: 574-315-3351
  • Fax: 574-272-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number31002539A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200703370A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: AMY R KENDALL
Title or Position: OWNER
Credential: OTR
Phone: 574-315-3351