Healthcare Provider Details

I. General information

NPI: 1629504303
Provider Name (Legal Business Name): LIFE'S JOURNEY OF AVON,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 HAWTHORNE DR STE 600
PLAINFIELD IN
46168-2815
US

IV. Provider business mailing address

1620 HAWTHORNE DR STE 600
PLAINFIELD IN
46168-2815
US

V. Phone/Fax

Practice location:
  • Phone: 317-561-6840
  • Fax: 317-561-6827
Mailing address:
  • Phone: 317-561-6840
  • Fax: 317-561-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ROBERT D WALLACE
Title or Position: CEO
Credential:
Phone: 317-561-6840