Provider Demographics
NPI:1073326021
Name:KOKOMO PLACE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:KOKOMO PLACE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-740-3220
Mailing Address - Street 1:5904 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7637
Mailing Address - Country:US
Mailing Address - Phone:260-740-3220
Mailing Address - Fax:260-498-2059
Practice Address - Street 1:3025 W SYCAMORE ST OFC
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4177
Practice Address - Country:US
Practice Address - Phone:765-456-1490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility