MEDICARE: PRISTINE SENIOR LIVING OF NORWOOD TOWERS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1104288612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISTINE SENIOR LIVING OF NORWOOD TOWERS, LLC

Provider Business Mailing Address
First Line	:	1301 E RIGGIN RD
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-9413
Country	:	US
Telephone Number	:	765-288-2488
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 SHERMAN AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45212-2510
Country	:	US
Telephone Number	:	513-631-6800
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CHRISTOPHER COOK
Credential	:
Telephone Number	:	765-288-2488

Provider Enumeration Date	:	03/23/2016
Last Update Date	:	03/23/2016

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