Basic Information
| Provider Information | |||||||||
| NPI: | 1225397011 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTRY CHARM VILLAGE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7212 U.S. HWY 31 S. | ||||||||
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| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462278549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178899822 | ||||||||
| FaxNumber: | 3178896500 | ||||||||
| Practice Location | |||||||||
| Address1: | 7212 US 31 S | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462278549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178899822 | ||||||||
| FaxNumber: | 3178896500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 05/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | VAN DER VELDE | ||||||||
| AuthorizedOfficialFirstName: | C. | ||||||||
| AuthorizedOfficialMiddleName: | DIEDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5025007798 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 12-003283-1 | IN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.