Provider Demographics
NPI:1801020375
Name:LAGRANGE COUNTY COUNCIL ON AGING
Entity Type:Organization
Organization Name:LAGRANGE COUNTY COUNCIL ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-463-4161
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:125 W FENN STREET
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0107
Mailing Address - Country:US
Mailing Address - Phone:260-463-4161
Mailing Address - Fax:260-572-2238
Practice Address - Street 1:125 W FENN ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2285
Practice Address - Country:US
Practice Address - Phone:260-463-4161
Practice Address - Fax:260-572-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200110800Medicaid