Provider Demographics
NPI:1083036974
Name:CAPITAL SENIOR LIVING PROPERTIES 4, INC.
Entity Type:Organization
Organization Name:CAPITAL SENIOR LIVING PROPERTIES 4, INC.
Other - Org Name:CSL FORT WAYNE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP AND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-770-5600
Mailing Address - Street 1:3320 EAST STATE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805
Mailing Address - Country:US
Mailing Address - Phone:260-483-4343
Mailing Address - Fax:812-406-1101
Practice Address - Street 1:3320 EAST STATE BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-483-4343
Practice Address - Fax:812-406-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13-012107-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility