Healthcare Provider Details

I. General information

NPI: 1124561873
Provider Name (Legal Business Name): INDIAN LAKE HEALTHCARE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14442 US HIGHWAY 33
LAKEVIEW OH
43331-9284
US

IV. Provider business mailing address

23700 COMMERCE PARK
BEACHWOOD OH
44122-5827
US

V. Phone/Fax

Practice location:
  • Phone: 937-843-4929
  • Fax: 937-843-3936
Mailing address:
  • Phone: 216-292-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIAM I WEISBERG
Title or Position: PRESIDENT
Credential:
Phone: 216-292-5706