Basic Information
| Provider Information | |||||||||
| NPI: | 1780702662 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORMAL LIFE OF INDIANA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRIPLE CROWN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 LINN STATION RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402233808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008660860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 415 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BOONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476011717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124333535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OMBRES | ||||||||
| AuthorizedOfficialFirstName: | DEENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRIVACY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5023942387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 100234140A | 05 | IN | MEDICAID |