Healthcare Provider Details

I. General information

NPI: 1710460936
Provider Name (Legal Business Name): LIFE'S JOURNEY OF AVON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/13/2018
Certification Date:
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: 317-561-6838
  • Fax: 317-561-6827
Mailing address:
  • Phone: 317-561-6838
  • Fax: 317-561-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State

VIII. Authorized Official

Name: ROBERT D WALLACE
Title or Position: CEO
Credential:
Phone: 317-561-6838