Basic Information
| Provider Information | |||||||||
| NPI: | 1548753403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TERRE HAUTE AAL LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SILVER BIRCH OF TERRE HAUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W WACKER DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606011781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122393534 | ||||||||
| FaxNumber: | 3124881919 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 LAFAYETTE AVENUE | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122370123 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | COCAGNE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER OF GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3122393534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.