=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083938914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME BY CHOICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2010
-----------------------------------------------------
Last Update Date | 03/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1237 N CONCORD RD
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-9097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-361-0600
-----------------------------------------------------
Fax | 765-364-1100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1237 N CONCORD RD
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-9097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-361-0600
-----------------------------------------------------
Fax | 765-364-1100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ROBERT S COOK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-362-4020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 100122701
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------