Healthcare Provider Details

I. General information

NPI: 1073789467
Provider Name (Legal Business Name): HOMEFRONT FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 E 100 S
GREENTOWN IN
46936-9163
US

IV. Provider business mailing address

9909 E 100 S
GREENTOWN IN
46936-9163
US

V. Phone/Fax

Practice location:
  • Phone: 765-628-0605
  • Fax: 765-628-3639
Mailing address:
  • Phone: 765-628-0605
  • Fax: 765-628-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number37001000
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number05006820
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number31002242
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22004012
License Number StateIN

VIII. Authorized Official

Name: AMY ELLIS
Title or Position: OWNER
Credential:
Phone: 765-628-0605