Basic Information
Provider Information | |||||||||
NPI: | 1871531459 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE WATERS OF PRINCETON, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 W VINE ST | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | IN | ||||||||
PostalCode: | 476701164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123855238 | ||||||||
FaxNumber: | 8123867471 | ||||||||
Practice Location | |||||||||
Address1: | 1020 W VINE ST | ||||||||
Address2: |   | ||||||||
City: | PRINCETON | ||||||||
State: | IN | ||||||||
PostalCode: | 476701164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123855238 | ||||||||
FaxNumber: | 8123867471 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 05/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLISKO | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7084491900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05-000175-1 | IN | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 000000381545 | 01 | IN | ANTHEM BCBS | OTHER | 100274440C | 05 | IN |   | MEDICAID | 000000476418 | 01 | IN | ANTHEM PT | OTHER | 000000476419 | 01 | IN | ANTHEM OT | OTHER | 000000476417 | 01 | IN | ANTHEM ST | OTHER |