Provider Demographics
NPI:1871306506
Name:INDIGO BRIDGE CARE LLC
Entity type:Organization
Organization Name:INDIGO BRIDGE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEKELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-252-8015
Mailing Address - Street 1:4609 NICOLET AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-5666
Mailing Address - Country:US
Mailing Address - Phone:715-252-8015
Mailing Address - Fax:
Practice Address - Street 1:W177N9886 RIVERCREST DR STE 262
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4601
Practice Address - Country:US
Practice Address - Phone:715-252-8015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-28
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care