Basic Information
| Provider Information | |||||||||
| NPI: | 1376896258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA HEALTH SYSTEMS 41, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROWNPOINTE OF CARMEL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9480 PRIORITY WAY WEST DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462401470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178181240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11610 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460325600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178181786 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3178181240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 120003091 | IN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 200928160C | 05 | IN | MEDICAID |