Healthcare Provider Details

I. General information

NPI: 1679876940
Provider Name (Legal Business Name): TRIUMPH REHABILITATION HOSPITAL NORTHERN INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W 4TH ST SUITE 200
MISHAWAKA IN
46544-1917
US

IV. Provider business mailing address

215 W 4TH ST SUITE 200
MISHAWAKA IN
46544-1917
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-5000
  • Fax: 574-280-5889
Mailing address:
  • Phone: 574-252-5000
  • Fax: 574-280-5889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: MARILYN A. WEAVER
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 502-596-7563