Healthcare Provider Details

I. General information

NPI: 1225397011
Provider Name (Legal Business Name): COUNTRY CHARM VILLAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 US 31 S
INDIANAPOLIS IN
46227-8549
US

IV. Provider business mailing address

7212 U.S. HWY 31 S.
INDIANAPOLIS IN
46227-8549
US

V. Phone/Fax

Practice location:
  • Phone: 317-889-9822
  • Fax: 317-889-6500
Mailing address:
  • Phone: 317-889-9822
  • Fax: 317-889-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number12-003283-1
License Number StateIN

VIII. Authorized Official

Name: MR. C. DIEDERICK VAN DER VELDE
Title or Position: PRESIDENT
Credential:
Phone: 502-500-7798