Basic Information
| Provider Information | |||||||||
| NPI: | 1306884994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE WATERS OF HUNTINGBURG, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1712 N LELAND DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475429348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126834090 | ||||||||
| FaxNumber: | 8126832305 | ||||||||
| Practice Location | |||||||||
| Address1: | 1712 N LELAND DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475429348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126834090 | ||||||||
| FaxNumber: | 8126832305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 05/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLISKO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7084491900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05-000122-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000391203 | 01 | IN | ANTHEM ST | OTHER | 000000391202 | 01 | IN | ANTHEM PT | OTHER | 100290560C | 05 | IN | MEDICAID | 000000391200 | 01 | IN | ANTHEM OT | OTHER | 000000381425 | 01 | IN | ANTHEM BCBS | OTHER | 5586190001 | 01 | IN | DMERC REGION B SUPPLIER# | OTHER |