Basic Information
| Provider Information | |||||||||
| NPI: | 1164723722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOME HEALTH DEPOT INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9245 N MERIDIAN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173336033 | ||||||||
| FaxNumber: | 3173336034 | ||||||||
| Practice Location | |||||||||
| Address1: | 7717 KENSINGTON CT | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481168561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482647099 | ||||||||
| FaxNumber: | 2482647097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2010 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLDMAN | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3173336033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | MI | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332BC3200X | MI | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1609935584 | 05 | MI | MEDICAID |