MEDICARE: LIFE'S JOURNEY OF AVON, LLC

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	315D00000X	Inpatient Hospice
2	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1710460936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE'S JOURNEY OF AVON, LLC

Provider Business Mailing Address
First Line	:	10241 E COUNTY ROAD 100 N
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-9016
Country	:	US
Telephone Number	:	317-561-6838
Fax Number	:	317-561-6827

Provider Business Practice Location Address
First Line	:	10241 E COUNTY ROAD 100 N
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-9016
Country	:	US
Telephone Number	:	317-561-6838
Fax Number	:	317-561-6827

Authorized Official
Title or Position	:	CEO
Name	:	ROBERT D WALLACE
Credential	:
Telephone Number	:	317-561-6838

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	09/13/2018

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