Healthcare Provider Details

I. General information

NPI: 1366389132
Provider Name (Legal Business Name): AMBASSADOR'S GROVE HOUSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7515 COBBLEWOOD LN UNIT 109
GRANGER IN
46530-1526
US

IV. Provider business mailing address

7515 COBBLEWOOD LN UNIT 109
GRANGER IN
46530-1526
US

V. Phone/Fax

Practice location:
  • Phone: 574-520-0406
  • Fax:
Mailing address:
  • Phone: 574-520-0406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MONIQUE SHURN
Title or Position: MANAGING MEMBER
Credential:
Phone: 574-520-0406