MEDICARE: PLYMOUTH NH, 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		IN

General Provider Information

NPI Number	:	1467457044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLYMOUTH NH, LLC

Provider Business Mailing Address
First Line	:	309 N KINGSTON RD
Second Line	:
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-1927
Country	:	US
Telephone Number	:	574-936-9025
Fax Number	:	574-936-4928

Provider Business Practice Location Address
First Line	:	309 N KINGSTON RD
Second Line	:
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-1927
Country	:	US
Telephone Number	:	574-936-9025
Fax Number	:	574-936-4928

Authorized Official
Title or Position	:	CFO
Name	:	WILLIAM MANDO
Credential	:
Telephone Number	:	813-635-9500

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	08/22/2020

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