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General NPI Number Information
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NPI Number | 1265553606
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Entity Type | Organization
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Legal Business Name | CORVILLA INC.
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 18443 BULLA RD
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City | SOUTH BEND
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State | IN
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Zip | 46637-5426
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Country | US
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Telephone | 574-277-8129
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Fax |
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Provider Business Mailing Address
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Address Line | 3231 SUGAR MAPLE BUSINESS CT
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City | SOUTH BEND
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State | IN
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Zip | 46628-4372
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Country | US
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Telephone | 574-289-9779
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Fax | 574-289-0185
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. JULIE A LUCKY
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Credential | MPA
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Telephone | 574-289-9779
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | IN
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