Healthcare Provider Details

I. General information

NPI: 1720195597
Provider Name (Legal Business Name): HOOSIER VILLAGE RETIREMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9875 CHERRYLEAF DR
INDIANAPOLIS IN
46268-3940
US

IV. Provider business mailing address

9875 CHERRYLEAF DR
INDIANAPOLIS IN
46268-3940
US

V. Phone/Fax

Practice location:
  • Phone: 317-873-3371
  • Fax: 317-873-4856
Mailing address:
  • Phone: 317-873-3371
  • Fax: 317-873-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number05-1000548-1
License Number StateIN

VIII. Authorized Official

Name: ROGER WEIDEMAN
Title or Position: CFO
Credential:
Phone: 317-873-3371