Basic Information
| Provider Information | |||||||||
| NPI: | 1902801574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MLB MERIDIAN HEALTH FACILITIES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MERIDIAN NURSING AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 S MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462251923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177869426 | ||||||||
| FaxNumber: | 3177869428 | ||||||||
| Practice Location | |||||||||
| Address1: | 2102 S MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462251923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177869426 | ||||||||
| FaxNumber: | 3177869428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANDO | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8136359500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 10028620D | 05 | IN | MEDICAID |