1518342583 NPI number — PRISTINE SENIOR LIVING OF BEAVERCREEK, LLC

Table of content: (NPI 1518342583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518342583 NPI number — PRISTINE SENIOR LIVING OF BEAVERCREEK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRISTINE SENIOR LIVING OF BEAVERCREEK, LLC
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:
1518342583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 W PURDUE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47304-6356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-408-8491
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3854 PARK OVERLOOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERCREEK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45431-5801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-429-9655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
317-408-8491

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0063595 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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