MEDICARE: GLASSHOUSE FAMILY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1093179871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLASSHOUSE FAMILY SERVICES

Provider Business Mailing Address
First Line	:	6145 LAKE FREEMAN DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-6913
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6145 LAKE FREEMAN DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-6913
Country	:	US
Telephone Number	:	317-938-1735
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MR. EUGENE DULLEN JR.
Credential	:
Telephone Number	:	317-938-1735

Provider Enumeration Date	:	04/07/2016
Last Update Date	:	04/07/2016

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