Provider Demographics
NPI:1821159641
Name:TEAM SELECT HOME CARE OF INDIANA, LLC
Entity Type:Organization
Organization Name:TEAM SELECT HOME CARE OF INDIANA, LLC
Other - Org Name:TEAM SELECT HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-185-7604
Mailing Address - Street 1:2999 N 44TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-7247
Mailing Address - Country:US
Mailing Address - Phone:480-618-5760
Mailing Address - Fax:
Practice Address - Street 1:413 N WASHINGTON ST STE 1
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4503
Practice Address - Country:US
Practice Address - Phone:765-201-4314
Practice Address - Fax:765-205-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-005843-1251E00000X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300059114OtherMEDICAID WAIVER
IN300058717Medicaid