Healthcare Provider Details

I. General information

NPI: 1154449817
Provider Name (Legal Business Name): VISTULA PARK PRESCHOOL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N TOWNLINE RD
LAGRANGE IN
46761-1136
US

IV. Provider business mailing address

603 N TOWNLINE RD
LAGRANGE IN
46761-1136
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-2363
  • Fax: 260-463-2933
Mailing address:
  • Phone: 260-463-2363
  • Fax: 260-463-2933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER LYNN MOTZ
Title or Position: PROGRAM DIRECTOR
Credential: MSW
Phone: 260-463-2363