Healthcare Provider Details

I. General information

NPI: 1366827941
Provider Name (Legal Business Name): PRISTINE SENIOR LIVING OF ENGLEWOOD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 LAURICELLA COURT
ENGLEWOOD OH
45322-0340
US

IV. Provider business mailing address

3301 W PURDUE AVE
MUNCIE IN
47304-6356
US

V. Phone/Fax

Practice location:
  • Phone: 937-836-5143
  • Fax:
Mailing address:
  • Phone: 317-408-8491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CHRISTOPHER T COOK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 317-408-8491