1457509044 NPI number — BELL TRACE HEALTH AND LIVING CENTER

Table of content: (NPI 1457509044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457509044 NPI number — BELL TRACE HEALTH AND LIVING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELL TRACE HEALTH AND LIVING CENTER
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:
Provider Other Organization Name Type Code:
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:
1457509044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 N BELL TRACE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47408-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-323-2858
Provider Business Mailing Address Fax Number:
812-323-2854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 N BELL TRACE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47408-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-323-2858
Provider Business Practice Location Address Fax Number:
812-323-2854
Provider Enumeration Date:
09/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
812-332-2265

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  05003924A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 05003924A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100581 . This is a "COMMON ID PIN # FOR ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".