Basic Information
| Provider Information | |||||||||
| NPI: | 1295945731 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROLLING MEADOWS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1810 W WESTLEA DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469522445 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 604 RENNAKER ST. | ||||||||
| Address2: | ROLLING MEADOWS HEALTH CARE CENTER | ||||||||
| City: | LAFONTAINE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659812081 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BANEZ | ||||||||
| AuthorizedOfficialFirstName: | JO | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGISTERED PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7655067373 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05008821A | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.