Healthcare Provider Details

I. General information

NPI: 1285723734
Provider Name (Legal Business Name): WOODLAWN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 GRACE VILLAGE DR
WINONA LAKE IN
46590-5774
US

IV. Provider business mailing address

337 GRACE VILLAGE DR
WINONA LAKE IN
46590-5774
US

V. Phone/Fax

Practice location:
  • Phone: 574-372-6200
  • Fax: 574-372-6386
Mailing address:
  • Phone: 574-372-6200
  • Fax: 574-372-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number060005011
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number060005011
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number060005011
License Number StateIN

VIII. Authorized Official

Name: JOHN ALLEY
Title or Position: PRESIDENT/CEO
Credential:
Phone: 574-223-3141