Basic Information
| Provider Information | |||||||||
| NPI: | 1225373343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKDALE SENIOR LIVING COMMUNITIES INC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STERLING HOUSE OF KOKOMO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3025 W SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469014176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654561490 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3025 W SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469014176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654561490 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2012 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIJOS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 3129773700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKDALE SENIOR LIVING | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 12-011075-1 | IN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | APPLIED FOR | 01 | IN | MEDICAID WAIVER | OTHER |