Provider Demographics
NPI:1336598358
Name:GREATLAND HEALTHCARE OF INDIANA INC.
Entity type:Organization
Organization Name:GREATLAND HEALTHCARE OF INDIANA INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONSURU
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-595-5081
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-0141
Mailing Address - Country:US
Mailing Address - Phone:219-595-5081
Mailing Address - Fax:219-513-9215
Practice Address - Street 1:2633 45TH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2902
Practice Address - Country:US
Practice Address - Phone:219-595-5081
Practice Address - Fax:219-513-9215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN19-013891-1OtherSTATE LICENSE