Basic Information
Provider Information | |||||||||
NPI: | 1750682738 | ||||||||
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: | 105 KRISPY KREME DR | ||||||||
Address2: | SUITE 3 | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IL | ||||||||
PostalCode: | 617043751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096624606 | ||||||||
FaxNumber: | 3096631916 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2010 | ||||||||
LastUpdateDate: | 01/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOLDMAN | ||||||||
AuthorizedOfficialFirstName: | TERRI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CONTRACTING | ||||||||
AuthorizedOfficialTelephone: | 3173336033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 203.001290 | IL | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332BX2000X | 203.001290 | IL | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X | 203.001290 | IL | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.