{
"Npi": {
"NPI": "1629367800",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GRACE HOSPICE OF INDIANA, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "500 KIRTS BLVD",
"SecondLineMailingAddress": "ATTN: CREDENTIALING DEPARTMENT",
"MailingAddressCityName": "TROY",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48084-4134",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "248-824-6000",
"MailingAddressFaxNumber": "855-618-6655",
"FirstLinePracticeLocationAddress": "5838 WEST BRICK RD",
"SecondLinePracticeLocationAddress": "STE 101",
"PracticeLocationAddressCityName": "SOUTH BEND",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "46628-8420",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "574-208-9270",
"PracticeLocationAddressFaxNumber": "855-618-0518",
"EnumerationDate": "03/29/2011",
"LastUpdateDate": "06/12/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VASEY",
"AuthorizedOfficialFirstName": "SCOTT",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRESIDENT - HOME HEALTH & HOSPICE",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "609-781-1535",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251G00000X",
"TaxonomyName": "Community Based Hospice Care Agency",
"LicenseNumber": "11-012733-1",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}