Provider Demographics
NPI:1427171933
Name:INDIVIDUAL SUPPORT SERVICES
Entity type:Organization
Organization Name:INDIVIDUAL SUPPORT SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-354-9009
Mailing Address - Street 1:7665 N RAIDER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47356-9401
Mailing Address - Country:US
Mailing Address - Phone:765-354-9009
Mailing Address - Fax:765-354-9090
Practice Address - Street 1:7665 N RAIDER RD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:IN
Practice Address - Zip Code:47356-9401
Practice Address - Country:US
Practice Address - Phone:765-354-9009
Practice Address - Fax:765-354-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN011160251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health