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General NPI Number Information
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NPI Number | 1598310005
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Entity Type | Organization
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Legal Business Name | THE WYNDMOOR OF PORTAGE, LLC
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Dates
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Enumeration Date | 08/02/2019
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Last Update Date | 08/02/2019
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Provider Practice Location Address
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Address Line | 3444 SWANSON RD
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City | PORTAGE
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State | IN
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Zip | 46368-4999
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Country | US
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Telephone | 219-763-4867
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Fax | 219-299-6570
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Provider Business Mailing Address
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Address Line | 3444 SWANSON RD
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City | PORTAGE
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State | IN
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Zip | 46368-4999
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Country | US
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Telephone | 219-763-4867
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Fax | 219-299-6570
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MS. LACHELE HENKLE WEAVER
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Credential | HFA, MBA, CLSS
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Telephone | 317-258-7031
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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 |
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License Number State |
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