Healthcare Provider Details

I. General information

NPI: 1780025163
Provider Name (Legal Business Name): SUZY Q SERVICE CORORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 N TIBBS AVE
INDIANAPOLIS IN
46222
US

IV. Provider business mailing address

2401 N TIBBS AVE
INDIANAPOLIS IN
46222-2457
US

V. Phone/Fax

Practice location:
  • Phone: 317-955-7567
  • Fax: 317-955-7567
Mailing address:
  • Phone: 317-955-7567
  • Fax: 317-955-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number130130671
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number18-013067-1
License Number StateIN

VIII. Authorized Official

Name: MS. SUZETT MOFFITT
Title or Position: PRESIDENT
Credential:
Phone: 317-755-7664