1083036974 NPI number — CAPITAL SENIOR LIVING PROPERTIES 4, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083036974 NPI number — CAPITAL SENIOR LIVING PROPERTIES 4, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL SENIOR LIVING PROPERTIES 4, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CSL FORT WAYNE, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083036974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3320 EAST STATE BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-483-4343
Provider Business Mailing Address Fax Number:
812-406-1101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3320 EAST STATE BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-483-4343
Provider Business Practice Location Address Fax Number:
812-406-1101
Provider Enumeration Date:
01/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KENYON
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP AND SECRETARY
Authorized Official Telephone Number:
972-770-5600

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  13-012107-1 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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