Healthcare Provider Details

I. General information

NPI: 1568905461
Provider Name (Legal Business Name): DYCORA TRANSITIONAL HEALTH - PORTAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 LANCER ST
PORTAGE IN
46368-4407
US

IV. Provider business mailing address

3175 LANCER ST
PORTAGE IN
46368-4407
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-9571
  • Fax:
Mailing address:
  • Phone: 219-762-9571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateIN

VIII. Authorized Official

Name: MARY HAWKINS
Title or Position: EXECUTIVE
Credential:
Phone: 219-762-9571