Healthcare Provider Details

I. General information

NPI: 1679601116
Provider Name (Legal Business Name): WESLEYAN HOMES OF INDIANA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 S MAIN ST
CLOVERDALE IN
46120-8531
US

IV. Provider business mailing address

580 LONG HILL AVE
SHELTON CT
06484-4803
US

V. Phone/Fax

Practice location:
  • Phone: 765-795-4260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number060004151
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100291250
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name: DAVID LAWLOR
Title or Position: VICE PRESIDENT
Credential:
Phone: 203-944-8285