Healthcare Provider Details

I. General information

NPI: 1679502439
Provider Name (Legal Business Name): HICKORY CREEK HEALTHCARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 FOUNTAIN ST
HICKSVILLE OH
43526-1337
US

IV. Provider business mailing address

6081 E 82ND ST SUITE 120
INDIANAPOLIS IN
46250-1795
US

V. Phone/Fax

Practice location:
  • Phone: 419-542-7795
  • Fax: 419-542-9765
Mailing address:
  • Phone: 317-570-0266
  • Fax: 317-570-0488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1289N
License Number StateOH

VIII. Authorized Official

Name: MR. GARY BRENT WAYMIRE
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 317-570-0266