Healthcare Provider Details

I. General information

NPI: 1497417828
Provider Name (Legal Business Name): LIFES JOURNEY PALLIATIVE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10241 E COUNTY ROAD 100 N
INDIANAPOLIS IN
46234-9016
US

IV. Provider business mailing address

10241 E COUNTY ROAD 100 N
INDIANAPOLIS IN
46234-9016
US

V. Phone/Fax

Practice location:
  • Phone: 812-239-3771
  • Fax: 317-561-6827
Mailing address:
  • Phone: 812-239-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT D WALLACE
Title or Position: MEMBER
Credential:
Phone: 812-239-3771