Healthcare Provider Details

I. General information

NPI: 1609871292
Provider Name (Legal Business Name): MCCARROLL MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 N TIBBS AVE
INDIANAPOLIS IN
46222-3024
US

IV. Provider business mailing address

1316 N TIBBS AVE
INDIANAPOLIS IN
46222-3024
US

V. Phone/Fax

Practice location:
  • Phone: 317-634-8330
  • Fax: 317-263-9442
Mailing address:
  • Phone: 317-634-8330
  • Fax: 317-263-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number05004731
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number050004731
License Number StateIN

VIII. Authorized Official

Name: MR. DAVID L MCCARROLL
Title or Position: PRESIDENT
Credential:
Phone: 317-634-8330