Basic Information
| Provider Information | |||||||||
| NPI: | 1407927098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VINCENNES OPERATOR, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CRESTVIEW HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7400 NEW LAGRANGE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298062 | ||||||||
| FaxNumber: | 5024295980 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 OLD BRUCEVILLE RD | ||||||||
| Address2: | BOX 216 | ||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475913889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128821783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TSCHUDI | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | CRAIG | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5024298062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 6295 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.