Basic Information
| Provider Information | |||||||||
| NPI: | 1376560169 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE WYNDMOOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2749 E COVENANTER DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474015454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123322265 | ||||||||
| FaxNumber: | 8123340853 | ||||||||
| Practice Location | |||||||||
| Address1: | 1465 E CROSSING BLVD | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478025315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122989963 | ||||||||
| FaxNumber: | 8122990660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8123322265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | IN00000 | IN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | IN0000 | 01 | IN | ASSISTED LIVING FACILITY | OTHER |