Provider Demographics
NPI:1114137296
Name:FLATROCK RIVER LODGE, LP
Entity Type:Organization
Organization Name:FLATROCK RIVER LODGE, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-932-2974
Mailing Address - Street 1:904 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-1368
Mailing Address - Country:US
Mailing Address - Phone:765-932-2974
Mailing Address - Fax:
Practice Address - Street 1:904 E 11TH ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-1368
Practice Address - Country:US
Practice Address - Phone:765-932-2974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4818314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155630Medicare ID - Type Unspecified