Provider Demographics
NPI:1285063958
Name:INDIAN CREEK OPERATING COMPANY LLC
Entity type:Organization
Organization Name:INDIAN CREEK OPERATING COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR AR
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-5728
Mailing Address - Street 1:6515 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1728
Mailing Address - Country:US
Mailing Address - Phone:913-642-5545
Mailing Address - Fax:
Practice Address - Street 1:6515 W 103RD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1728
Practice Address - Country:US
Practice Address - Phone:913-642-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS175176Medicare Oscar/Certification