Basic Information
| Provider Information | |||||||||
| NPI: | 1831335637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA HEALTH SYSTEM IX, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUMMIT PLACE WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9455 DELEGATES ROW | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462403805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178181240 | ||||||||
| FaxNumber: | 3178181430 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 MISSION DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462145907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172442600 | ||||||||
| FaxNumber: | 3172443771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2008 | ||||||||
| LastUpdateDate: | 12/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAINO | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3172442600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 080118401 | IN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.