Healthcare Provider Details

I. General information

NPI: 1275743205
Provider Name (Legal Business Name): DUNGARVIN INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 MOREAU CT STE 200
SOUTH BEND IN
46628-4387
US

IV. Provider business mailing address

1444 NORTHLAND DR STE 200
MENDOTA HEIGHTS MN
55120-1032
US

V. Phone/Fax

Practice location:
  • Phone: 574-245-5400
  • Fax: 574-245-5440
Mailing address:
  • Phone: 651-699-0206
  • Fax: 651-699-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LORI KRESS
Title or Position: CEO
Credential:
Phone: 651-699-0206