Provider Demographics
NPI:1376816702
Name:111HOME HEALTH CARE AGENCY
Entity Type:Organization
Organization Name:111HOME HEALTH CARE AGENCY
Other - Org Name:111HOME PERSONAL CARE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:I
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:574-350-9831
Mailing Address - Street 1:336 W GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-2501
Mailing Address - Country:US
Mailing Address - Phone:574-350-9831
Mailing Address - Fax:574-293-7947
Practice Address - Street 1:336 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2501
Practice Address - Country:US
Practice Address - Phone:574-350-9831
Practice Address - Fax:574-293-7947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-012725-1253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care