Provider Demographics
NPI:1629367800
Name:GRACE HOSPICE OF INDIANA, LLC
Entity Type:Organization
Organization Name:GRACE HOSPICE OF INDIANA, LLC
Other - Org Name:HARMONYCARES HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-824-6000
Mailing Address - Street 1:500 KIRTS BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4134
Mailing Address - Country:US
Mailing Address - Phone:248-824-6000
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:5838 WEST BRICK RD
Practice Address - Street 2:STE 101
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-8420
Practice Address - Country:US
Practice Address - Phone:574-208-9270
Practice Address - Fax:855-618-0518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-012733-1251G00000X, 251G00000X
251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18-012733-1OtherSTATE OF INDIANA HOSPICE LICENSE
IN201123200AMedicaid
IN201123200AMedicaid