=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174311674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. WILLIE CARSON SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2025
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2730 LOIS ST # 1
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-654-3019
-----------------------------------------------------
Fax | 219-406-0162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2730 LOIS ST # 1
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-654-3019
-----------------------------------------------------
Fax | 219-406-0162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------