Provider Demographics
NPI:1861667941
Name:KOSCIUSKO HOME CARE & HOSPICE INC
Entity Type:Organization
Organization Name:KOSCIUSKO HOME CARE & HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:PACZKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-372-3401
Mailing Address - Street 1:1515 PROVIDENT DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3294
Mailing Address - Country:US
Mailing Address - Phone:574-372-3401
Mailing Address - Fax:574-372-3415
Practice Address - Street 1:1515 PROVIDENT DR
Practice Address - Street 2:SUITE 250
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3294
Practice Address - Country:US
Practice Address - Phone:574-372-3401
Practice Address - Fax:574-372-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07-009511-1251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200297120Medicaid