CROSSROAD - FORT WAYNE CHILDRENS HOME
Ambulatory Health at Lake Ave, Fort Wayne, IN

License number
Indiana 7342602900837
Category
Ambulatory Health
Type
Adolescent and Children Mental Health
Owner
Name: MR. JC DOLLAR
Title: CEO/PRESIDENT
Phone: (260) 484-4153
Address
Address
2525 Lake Ave, Fort Wayne, IN 46805
National Provider ID: 1275614109
LicenseFiles verified this license of Nov 7, 2017 at the National Plan and Provider Enumeration System.

Organization information

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CROSSROAD FORT WAYNE CHILDREN'S HOME

Fort Wayne, IN

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Status:
Inactive
Registration:
Aug 29, 1997
State ID:
75349104
Reg. number:
2254894
Status:
710 - Cancelled - section 8
Status date:
Mar 25, 2006
Illustration:
Drawing or design which also includes word(s)/ letter(s)/number(s)
Attorney:
Randall J. Knuth,RANDALL J. KNUTH, PC,4921 Desoto Dr, Fort Wayne, IN 46815
Employee:
Howard B Levine
Goods & Services:
"fort wayne children's home", Operation of children's home
Owner:
2525 Lk Ave, Fort Wayne, IN 46805

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