MEDICARE: MCCORDSVILLE SENIOR LIVING, 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	310400000X	Assisted Living Facility		IN

General Provider Information

NPI Number	:	1639619919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCCORDSVILLE SENIOR LIVING, LLC

Provider Business Mailing Address
First Line	:	802 E 86TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1806
Country	:	US
Telephone Number	:	317-819-3205
Fax Number	:	317-893-7125

Provider Business Practice Location Address
First Line	:	6311 W COUNTY ROAD 900 NORTH
Second Line	:
City	:	MCCORDSVILLE
State	:	IN
Zip	:	46055
Country	:	US
Telephone Number	:	317-335-9900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. THOMAS SMITH
Credential	:
Telephone Number	:	317-819-3205

Provider Enumeration Date	:	03/06/2017
Last Update Date	:	03/06/2017

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