Healthcare Provider Details

I. General information

NPI: 1639991276
Provider Name (Legal Business Name): 11755 N MICHIGAN TENANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11755 N MICHIGAN RD
ZIONSVILLE IN
46077-9325
US

IV. Provider business mailing address

200 E COURT ST STE 400
KANKAKEE IL
60901-3848
US

V. Phone/Fax

Practice location:
  • Phone: 317-873-6300
  • Fax:
Mailing address:
  • Phone: 815-935-1992
  • Fax: 815-935-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. GREG ECHOLS
Title or Position: CO-PRESIDENT OF ITS MANAGEMENT AGEN
Credential:
Phone: 779-216-5849