=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689121253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HRS PRIVATE DUTY OF INDIANA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 09/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1806 S. HIGHLAND AVE
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-604-3742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 N BROAD STREET SUITE A
-----------------------------------------------------
City | GRIFFITH
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46319-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-604-3742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT MIKULAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-604-3740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 16-013872-1
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------