Provider Demographics
NPI:1750682738
Name:HOME HEALTH DEPOT INC
Entity Type:Organization
Organization Name:HOME HEALTH DEPOT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-333-6033
Mailing Address - Street 1:9245 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1836
Mailing Address - Country:US
Mailing Address - Phone:317-333-6033
Mailing Address - Fax:317-333-6034
Practice Address - Street 1:105 KRISPY KREME DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3751
Practice Address - Country:US
Practice Address - Phone:309-662-4606
Practice Address - Fax:309-663-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.001290332B00000X, 332BC3200X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid