=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396034237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK PLACE SENIOR LIVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2011
-----------------------------------------------------
Last Update Date | 03/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4411 PARK PLACE DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-8793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-480-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4411 PARK PLACE DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-8793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-480-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MS. LACHELE R HENKLE WEAVER
-----------------------------------------------------
Credential | HFA, MBA
-----------------------------------------------------
Telephone | 317-258-7031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------