Healthcare Provider Details

I. General information

NPI: 1760889570
Provider Name (Legal Business Name): HOMEFRONT FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 11/21/2014
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 TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number32002754A
License Number StateIN

VIII. Authorized Official

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