Basic Information
| Provider Information | |||||||||
| NPI: | 1851454573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE WATERS OF SCOTTSBURG, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9785 CROSSPOINT BLVD. | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 402563321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175989496 | ||||||||
| FaxNumber: | 3175989467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 N. TODD DRIVE | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471707755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127525663 | ||||||||
| FaxNumber: | 8127529853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | KEMPER | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3175989496 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 08-000478-1 | IN | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | 060004783 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100290430 | 05 | IN | MEDICAID | 100290430E | 05 | IN | MEDICAID |