Provider Demographics
NPI:1346496957
Name:MAKE SUPPORTIVE LIVING, LLC
Entity Type:Organization
Organization Name:MAKE SUPPORTIVE LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:
Authorized Official - Credentials:HOME CARE PROVIDER
Authorized Official - Phone:317-724-8778
Mailing Address - Street 1:P.O BOX 88492
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-0492
Mailing Address - Country:US
Mailing Address - Phone:317-724-8778
Mailing Address - Fax:
Practice Address - Street 1:1639 N PARK AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1720
Practice Address - Country:US
Practice Address - Phone:317-724-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAKE SUPPORTIVE LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health