Provider Demographics
NPI:1093750119
Name:ST. CLAIR DARDEN HEALTH SYSTEM INC
Entity Type:Organization
Organization Name:ST. CLAIR DARDEN HEALTH SYSTEM INC
Other - Org Name:HEALTHWIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. BUSINESS OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELYNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVERSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-272-0100
Mailing Address - Street 1:20531 DARDEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-2915
Mailing Address - Country:US
Mailing Address - Phone:574-272-0100
Mailing Address - Fax:574-271-8976
Practice Address - Street 1:20531 DARDEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-2915
Practice Address - Country:US
Practice Address - Phone:574-272-0100
Practice Address - Fax:574-271-8976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06-000073-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100288820AMedicaid
IN155153Medicare Oscar/Certification
IN4207830001Medicare NSC