Provider Demographics
NPI:1780025163
Name:SUZY Q SERVICE CORORATION
Entity Type:Organization
Organization Name:SUZY Q SERVICE CORORATION
Other - Org Name:SUZY Q CLEANING SERVICE LLC & PERSONAL SERVICE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZETT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-755-7664
Mailing Address - Street 1:2401 N TIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2457
Mailing Address - Country:US
Mailing Address - Phone:317-955-7567
Mailing Address - Fax:317-955-7567
Practice Address - Street 1:2401 N TIBBS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222
Practice Address - Country:US
Practice Address - Phone:317-955-7567
Practice Address - Fax:317-955-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN130130671253Z00000X
IN18-013067-1372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18-013067-1OtherINDIANA STATE DEPARTMENT OF HEALTH/PERSONAL SERVICE AGENCY
IN201172830AMedicaid