Basic Information
| Provider Information | |||||||||
| NPI: | 1124025457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER PROVIDERS INC DBA BRADNER VILLAGE HEALTH CARE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRADNER VILLAGE HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N BRADNER AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469522449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656623981 | ||||||||
| FaxNumber: | 7656623981 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N BRADNER AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469522449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656623981 | ||||||||
| FaxNumber: | 7656623981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALTS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7656623981 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | IN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.