Basic Information
| Provider Information | |||||||||
| NPI: | 1033295472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDWORKS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 S CALUMET RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463043286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199839675 | ||||||||
| FaxNumber: | 2199839681 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 S CALUMET RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463043286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199164960 | ||||||||
| FaxNumber: | 2197642751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | MANGAN | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2199839675 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32001204A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225200000X | 06003228A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225100000X | 05008714A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | 22003689A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | 31003944A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200815860 | 05 | IN | MEDICAID |