Healthcare Provider Details

I. General information

NPI: 1649275215
Provider Name (Legal Business Name): MLB CORYDON HEALTH FACILITIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 COUNTRY CLUB RD
CORYDON IN
47112-1751
US

IV. Provider business mailing address

315 COUNTRY CLUB RD
CORYDON IN
47112-1751
US

V. Phone/Fax

Practice location:
  • Phone: 813-738-2190
  • Fax: 812-738-3121
Mailing address:
  • Phone: 813-738-2190
  • Fax: 812-738-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: WILLIAM MANDO
Title or Position: CFO
Credential:
Phone: 813-635-9500