Provider Demographics
NPI:1285805275
Name:COUNTRY CHARM
Entity type:Organization
Organization Name:COUNTRY CHARM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:C
Authorized Official - Middle Name:DIEDERICK
Authorized Official - Last Name:VAN DER VELDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-882-5455
Mailing Address - Street 1:3177 MERIDIAN PARKE DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9629
Mailing Address - Country:US
Mailing Address - Phone:317-882-5455
Mailing Address - Fax:317-882-3606
Practice Address - Street 1:3177 MERIDIAN PARKE DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9629
Practice Address - Country:US
Practice Address - Phone:317-882-5455
Practice Address - Fax:317-882-3606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility