Provider Demographics
NPI:1043950801
Name:INDIGO CENTER FOR SENIOR LIVING LLC
Entity Type:Organization
Organization Name:INDIGO CENTER FOR SENIOR LIVING LLC
Other - Org Name:WOODLAND TOWERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MORDECHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-631-4068
Mailing Address - Street 1:113 W CHIPOLA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7512
Mailing Address - Country:US
Mailing Address - Phone:386-738-2700
Mailing Address - Fax:386-822-9296
Practice Address - Street 1:113 W CHIPOLA AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7512
Practice Address - Country:US
Practice Address - Phone:386-738-2700
Practice Address - Fax:386-822-9296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-30
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL7143OtherLICENSURE
FL113963100Medicaid