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General NPI Number Information
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NPI Number | 1942559745
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Entity Type | Organization
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Legal Business Name | INDYWOOD ESTATE, LLC
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Dates
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Enumeration Date | 09/07/2012
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Last Update Date | 09/07/2012
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Provider Practice Location Address
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Address Line | 218 RONALDMAN RD
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City | CLEVELAND
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State | MS
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Zip | 38732-8755
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Country | US
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Telephone | 662-843-7885
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Fax | 662-843-7985
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Provider Business Mailing Address
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Address Line | 1416 ERIE ST
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City | GREENWOOD
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State | MS
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Zip | 38930-2103
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Country | US
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Telephone | 662-455-3878
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Fax | 662-455-6171
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Authorized Official
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Title or Position | ASSISTANT MANAGER
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Name | MS. SHARON HARVEY
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Credential |
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Telephone | 662-455-3878
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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 | 960
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License Number State | MS
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