Healthcare Provider Details

I. General information

NPI: 1972077360
Provider Name (Legal Business Name): A.W. HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 1ST AVE
SPEARFISH SD
57783-3209
US

IV. Provider business mailing address

8515 BLUFFTON RD
FORT WAYNE IN
46809-3022
US

V. Phone/Fax

Practice location:
  • Phone: 605-644-7370
  • Fax:
Mailing address:
  • Phone: 260-744-6145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: NANCY ANN BOBAY
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 260-207-5604