Provider Demographics
NPI:1205216942
Name:GAHC3 MISHAWAKA IN ALF TRS SUB, LLC
Entity Type:Organization
Organization Name:GAHC3 MISHAWAKA IN ALF TRS SUB, LLC
Other - Org Name:TANGLEWOOD TRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-270-9200
Mailing Address - Street 1:530 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2627
Mailing Address - Country:US
Mailing Address - Phone:317-324-9563
Mailing Address - Fax:
Practice Address - Street 1:530 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2627
Practice Address - Country:US
Practice Address - Phone:317-324-9563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility