Healthcare Provider Details

I. General information

NPI: 1700511318
Provider Name (Legal Business Name): LACTATION DEPOT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 11/25/2022
Certification Date: 11/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10775 MCKINLEY HWY STE C
OSCEOLA IN
46561-9164
US

IV. Provider business mailing address

10275 PEOTONE DR
GRANGER IN
46530-7744
US

V. Phone/Fax

Practice location:
  • Phone: 574-315-3196
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KRISTIN SZERSZEN
Title or Position: CEO
Credential:
Phone: 574-315-3196