Provider Demographics
NPI:1164410197
Name:INDIAN RIVER CENTER, LLC
Entity Type:Organization
Organization Name:INDIAN RIVER CENTER, LLC
Other - Org Name:INDIAN RIVER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:819-852-7000
Mailing Address - Street 1:7201 GREENBORO DR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1698
Mailing Address - Country:US
Mailing Address - Phone:321-727-0990
Mailing Address - Fax:321-951-4553
Practice Address - Street 1:7201 GREENBORO DR
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1698
Practice Address - Country:US
Practice Address - Phone:321-727-0990
Practice Address - Fax:321-951-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1348096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08845OtherBLUE CROSS BLUE SHIELD MI
FL70-00474OtherEVERCARE HH CONNECTION
FL0005900226OtherAETNA
FLC105673OtherUNITED AMERICAN
FL026066500Medicaid
FLK3MOtherBLUE CROSS BLUE SHIELD
FLK3MOtherBLUE CROSS BLUE SHIELD
FL========= 32904 0000OtherTRICARE