Basic Information
| Provider Information | |||||||||
| NPI: | 1477766624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHCARE CENTERS OF INDIANA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE WATERS OF RISING SUN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GLEED AVE | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140522983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166522820 | ||||||||
| FaxNumber: | 7166552320 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 RIO VISTA LN | ||||||||
| Address2: | |||||||||
| City: | RISING SUN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470409497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124382219 | ||||||||
| FaxNumber: | 8124381268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | FELDMAN | ||||||||
| AuthorizedOfficialFirstName: | JOY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7168051474 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05000405-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100273800B | 05 | IN | MEDICAID |