Provider Demographics
NPI:1649055955
Name:BLACK PEARL LIFE SERVICES LLC
Entity type:Organization
Organization Name:BLACK PEARL LIFE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-757-1481
Mailing Address - Street 1:5534 SAINT JOE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3328
Mailing Address - Country:US
Mailing Address - Phone:219-614-9428
Mailing Address - Fax:
Practice Address - Street 1:4237 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-3529
Practice Address - Country:US
Practice Address - Phone:219-614-9428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care