Healthcare Provider Details

I. General information

NPI: 1740214493
Provider Name (Legal Business Name): HICKORY CREEK HEALTHCARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 PERRY WORTH RD
LEBANON IN
46052-9635
US

IV. Provider business mailing address

1585 PERRY WORTH RD
LEBANON IN
46052-9635
US

V. Phone/Fax

Practice location:
  • Phone: 765-482-6391
  • Fax: 765-483-2590
Mailing address:
  • Phone: 765-482-6391
  • Fax: 765-483-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. GARY BRENT WAYMIRE
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 317-570-0266