Provider Demographics
NPI:1851454573
Name:THE WATERS OF SCOTTSBURG, LLC
Entity type:Organization
Organization Name:THE WATERS OF SCOTTSBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:V
Authorized Official - Last Name:KEMPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-598-9496
Mailing Address - Street 1:9785 CROSSPOINT BLVD.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:40256-3321
Mailing Address - Country:US
Mailing Address - Phone:317-598-9496
Mailing Address - Fax:317-598-9467
Practice Address - Street 1:1350 N. TODD DRIVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7755
Practice Address - Country:US
Practice Address - Phone:812-752-5663
Practice Address - Fax:812-752-9853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08-000478-1310400000X
IN060004783314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100290430Medicaid
IN100290430EMedicaid
IN155494Medicare Oscar/Certification
IN155494Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER