Provider Demographics
NPI:1639748692
Name:LIFECARE OF INDIANA LLC
Entity Type:Organization
Organization Name:LIFECARE OF INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO / ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEESTMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-821-3485
Mailing Address - Street 1:240 COMMERCE SQ
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3282
Mailing Address - Country:US
Mailing Address - Phone:231-299-2900
Mailing Address - Fax:
Practice Address - Street 1:240 COMMERCE SQ
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3282
Practice Address - Country:US
Practice Address - Phone:219-324-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty