Basic Information
Provider Information | |||||||||
NPI: | 1780768754 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRINITY CONTINUING CARE SERVICES INDIANA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST PAUL'S RETIREMENT COMMUNITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9184 | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON HILLS | ||||||||
State: | MI | ||||||||
PostalCode: | 483339184 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483057919 | ||||||||
FaxNumber: | 2483057677 | ||||||||
Practice Location | |||||||||
Address1: | 3602 S IRONWOOD DR | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466142453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2192918205 | ||||||||
FaxNumber: | 2192910858 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2006 | ||||||||
LastUpdateDate: | 07/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | JACKIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2483057688 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 05-001201-1 | IN | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies |
ID Information
ID | Type | State | Issuer | Description | 100380860 | 05 | IN |   | MEDICAID |