Provider Demographics
NPI:1720763006
Name:WHEATFIELD RESIDENTIAL LLC
Entity Type:Organization
Organization Name:WHEATFIELD RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:STROUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-600-9640
Mailing Address - Street 1:4150 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1208
Mailing Address - Country:US
Mailing Address - Phone:219-235-9777
Mailing Address - Fax:
Practice Address - Street 1:12501 IN-49
Practice Address - Street 2:
Practice Address - City:WHEATFIELD
Practice Address - State:IN
Practice Address - Zip Code:46392
Practice Address - Country:US
Practice Address - Phone:219-235-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)