Provider Demographics
NPI:1730599374
Name:SPECIALIZED HOME CARE SERVICES LLC
Entity type:Organization
Organization Name:SPECIALIZED HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BODWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-538-3737
Mailing Address - Street 1:621 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2012
Mailing Address - Country:US
Mailing Address - Phone:317-538-3737
Mailing Address - Fax:
Practice Address - Street 1:621 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2012
Practice Address - Country:US
Practice Address - Phone:317-538-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN30005122A332BP3500X, 332BX2000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201286800AMedicaid