=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164852505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R&L SUPPORTIVE LIVING CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2013
-----------------------------------------------------
Last Update Date | 11/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3754 JACKSON ST
-----------------------------------------------------
City | GARY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46408-2226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-939-7556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3754 JACKSON ST
-----------------------------------------------------
City | GARY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46408-2226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RAMONA HERRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-939-7556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 33-2340044
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------