Healthcare Provider Details

I. General information

NPI: 1326677576
Provider Name (Legal Business Name): DISCOVERY NORTHSIDE ACQUISITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 W 96TH ST
INDIANAPOLIS IN
46260-1181
US

IV. Provider business mailing address

27599 RIVERVIEW CENTER BLVD STE 201
BONITA SPRINGS FL
34134-4327
US

V. Phone/Fax

Practice location:
  • Phone: 317-575-9200
  • Fax:
Mailing address:
  • Phone: 239-676-2346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: THOMAS COSTELLO
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 813-420-4052