Basic Information
| Provider Information | |||||||||
| NPI: | 1093963688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELL TRACE HEALTH AND LIVING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 N BELL TRACE CIR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474084408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123232858 | ||||||||
| FaxNumber: | 8123232854 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 N BELL TRACE CIR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474084408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123232858 | ||||||||
| FaxNumber: | 8123232854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8123322265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDON & ASSOCIAES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 22004493A | IN | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 235Z00000X | 22004493A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.