Basic Information
Provider Information | |||||||||
NPI: | 1194978940 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCCI HOSPITALS OF AMERICA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KINDRED HOSPITAL NORTHERN INDIANA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 680 S. 4TH ST. | ||||||||
Address2: | KH-2 REIMBURSEMENT | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402022407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025967220 | ||||||||
FaxNumber: | 5025964134 | ||||||||
Practice Location | |||||||||
Address1: | 215 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | MISHAWAKA | ||||||||
State: | IN | ||||||||
PostalCode: | 46544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742518238 | ||||||||
FaxNumber: | 5742805889 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2008 | ||||||||
LastUpdateDate: | 08/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DILLON | ||||||||
AuthorizedOfficialFirstName: | TERRANCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY / AO | ||||||||
AuthorizedOfficialTelephone: | 5025967220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X |   |   | Y |   | Hospitals | Long Term Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 200292860A | 05 | IN |   | MEDICAID |