1093389074 NPI number — KINDRED ANGELS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093389074 NPI number — KINDRED ANGELS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINDRED ANGELS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093389074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6230 E BLUE STAR HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGRO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46941-9457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-444-1231
Provider Business Mailing Address Fax Number:
844-929-0078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4210 FLAGSTAFF CV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46815-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-602-0977
Provider Business Practice Location Address Fax Number:
844-929-0078
Provider Enumeration Date:
05/14/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALLISCH
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER, DIRECTOR OF NURSING
Authorized Official Telephone Number:
260-444-1231

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)