Provider Demographics
NPI:1497001366
Name:LIVING HOME
Entity Type:Organization
Organization Name:LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ADEYANJU
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:317-291-9388
Mailing Address - Street 1:6350 WESTHAVEN DR STE F
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2731
Mailing Address - Country:US
Mailing Address - Phone:317-291-9388
Mailing Address - Fax:317-291-9389
Practice Address - Street 1:6350 WESTHAVEN DR STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2731
Practice Address - Country:US
Practice Address - Phone:317-291-9388
Practice Address - Fax:317-291-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility