Basic Information
| Provider Information | |||||||||
| NPI: | 1275572646 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE WATERS OF YORKTOWN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 FENCL LANE | ||||||||
| Address2: | |||||||||
| City: | HILLSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601622067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084491900 | ||||||||
| FaxNumber: | 7084491500 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 S. ANDREWS ROAD | ||||||||
| Address2: | |||||||||
| City: | YORKTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473966812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657597740 | ||||||||
| FaxNumber: | 7657597131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | SORSCHER | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7084491900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05-000143-1 | IN | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100283890C | 05 | IN | MEDICAID | 000000391196 | 01 | IN | ANTHEM ST | OTHER | 000000381429 | 01 | IN | ANTHEM BCBS | OTHER | 000000391199 | 01 | IN | ANTHEM OT | OTHER | 5584850001 | 01 | IN | DMERC REGION B SUPPLIER# | OTHER | 000000391198 | 01 | IN | ANTHEM PT | OTHER |