MEDICARE: COMMUNITY HOPSITAL OF LAGRANGE COUNTY,INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	01061887A	IN

General Provider Information

NPI Number	:	1316188667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY HOPSITAL OF LAGRANGE COUNTY,INC

Provider Business Mailing Address
First Line	:	1900 CAREW STREET
Second Line	:	SUITE 1
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4765
Country	:	US
Telephone Number	:	260-373-9700
Fax Number	:	260-373-9740

Provider Business Practice Location Address
First Line	:	8175 WEST US 20
Second Line	:
City	:	SHIPSHEWANA
State	:	IN
Zip	:	46565-9169
Country	:	US
Telephone Number	:	260-768-7432
Fax Number	:	260-768-7482

Authorized Official
Title or Position	:	EXECUTIVE VP--CFO
Name	:	MR. MARK NAFZIGER
Credential	:
Telephone Number	:	260-373-7008

Provider Enumeration Date	:	03/17/2009
Last Update Date	:	03/17/2009

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