Provider Demographics
NPI:1275743205
Name:DUNGARVIN INDIANA, LLC
Entity Type:Organization
Organization Name:DUNGARVIN INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-699-0206
Mailing Address - Street 1:1444 NORTHLAND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1032
Mailing Address - Country:US
Mailing Address - Phone:651-699-0206
Mailing Address - Fax:651-699-0799
Practice Address - Street 1:3575 MOREAU CT STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-4387
Practice Address - Country:US
Practice Address - Phone:574-245-5400
Practice Address - Fax:574-245-5440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUNGARVIN GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100239960Medicaid
IN100245120Medicaid
IN100245230Medicaid
IN100244770Medicaid
IN100244780Medicaid
IN100239800Medicaid
IN100244830Medicaid
IN100244950Medicaid
IN100230070Medicaid