Healthcare Provider Details

I. General information

NPI: 1720082456
Provider Name (Legal Business Name): SEACOAST OF CLARKSVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 GREENTREE N
CLARKSVILLE IN
47129-8958
US

IV. Provider business mailing address

PO BOX 501188
INDIANAPOLIS IN
46250
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-5911
  • Fax: 812-285-9830
Mailing address:
  • Phone: 317-806-6775
  • Fax: 317-806-6771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5471
License Number StateIN

VIII. Authorized Official

Name: MR. JOHN BARTLE JR.
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 317-806-6770