Provider Demographics
NPI:1528156874
Name:AAA HOOSIER HOME HC SPEC. INC.
Entity type:Organization
Organization Name:AAA HOOSIER HOME HC SPEC. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:CAMILLE
Authorized Official - Last Name:BANKHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:219-736-2996
Mailing Address - Street 1:5241 FOUNTAIN DR STE C-D
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-5323
Mailing Address - Country:US
Mailing Address - Phone:219-736-2996
Mailing Address - Fax:219-736-2998
Practice Address - Street 1:5241 FOUNTAIN DR STE C-D
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-5323
Practice Address - Country:US
Practice Address - Phone:219-736-2996
Practice Address - Fax:219-736-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050106071251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200197560AMedicaid