MEDICARE: DALE A ILLINGWORTH

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	372600000X	Adult Companion		IN

General Provider Information

NPI Number	:	1225658644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE A ILLINGWORTH

Provider Business Mailing Address
First Line	:	3621 RIBBON DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-8167
Country	:	US
Telephone Number	:	317-652-6667
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 RIBBON DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-8167
Country	:	US
Telephone Number	:	317-652-6667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2020
Last Update Date	:	04/26/2020

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Directions to “ DALE A ILLINGWORTH ” Practice Location

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