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General NPI Number Information
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NPI Number | 1629885280
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Entity Type | Organization
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Legal Business Name | PREMIUM CAREGIVER SUPPORTS LLC
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Dates
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Enumeration Date | 12/16/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 2345 MUNN CIR
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City | INDIANAPOLIS
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State | IN
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Zip | 46229-1479
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Country | US
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Telephone | 317-675-0088
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Fax |
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Provider Business Mailing Address
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Address Line | 2345 MUNN CIR
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City | INDIANAPOLIS
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State | IN
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Zip | 46229-1479
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Country | US
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Telephone | 317-675-0088
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MRS. JENNIFER FORD
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Credential | BSW
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Telephone | 317-675-0088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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