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General NPI Number Information
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NPI Number | 1346496957
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Entity Type | Organization
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Legal Business Name | MAKE SUPPORTIVE LIVING, LLC
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Dates
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Enumeration Date | 08/14/2008
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Last Update Date | 08/14/2008
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Provider Practice Location Address
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Address Line | 1639 N PARK AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-1720
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Country | US
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Telephone | 317-724-8778
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Fax |
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Provider Business Mailing Address
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Address Line | P.O BOX 88492
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City | INDIANAPOLIS
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State | IN
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Zip | 46208-0492
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Country | US
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Telephone | 317-724-8778
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MS. TAMARA NICOLE MIXON
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Credential | HOME CARE PROVIDER
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Telephone | 317-724-8778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | IN
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