Healthcare Provider Details

I. General information

NPI: 1467457044
Provider Name (Legal Business Name): PLYMOUTH NH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N KINGSTON RD
PLYMOUTH IN
46563-1927
US

IV. Provider business mailing address

309 N KINGSTON RD
PLYMOUTH IN
46563-1927
US

V. Phone/Fax

Practice location:
  • Phone: 574-936-9025
  • Fax: 574-936-4928
Mailing address:
  • Phone: 574-936-9025
  • Fax: 574-936-4928

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: WILLIAM MANDO
Title or Position: CFO
Credential:
Phone: 813-635-9500