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General NPI Number Information
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NPI Number | 1205908670
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Entity Type | Organization
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Legal Business Name | INDYWOOD LLC
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 09/16/2009
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Provider Practice Location Address
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Address Line | 541 DORSETT DR
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City | INDIANOLA
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State | MS
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Zip | 38751-2386
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Country | US
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Telephone | 662-887-3005
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Fax |
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Provider Business Mailing Address
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Address Line | 541 DORSETT DR
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City | INDIANOLA
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State | MS
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Zip | 38751-2386
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Country | US
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Telephone | 662-887-3005
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. ELETA J GRIMMETT
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Credential |
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Telephone | 662-534-2387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 838
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License Number State | MS
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