Provider Demographics
NPI:1134318553
Name:KINGSWAY COMMUNITY CARE CENTER
Entity Type:Organization
Organization Name:KINGSWAY COMMUNITY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MOLLAUN
Authorized Official - Last Name:P
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-272-0708
Mailing Address - Street 1:6722 E US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8921
Mailing Address - Country:US
Mailing Address - Phone:317-272-0708
Mailing Address - Fax:317-272-0918
Practice Address - Street 1:6722 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8921
Practice Address - Country:US
Practice Address - Phone:317-272-0708
Practice Address - Fax:317-272-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable