Provider Demographics
NPI:1225397011
Name:COUNTRY CHARM VILLAGE LLC
Entity Type:Organization
Organization Name:COUNTRY CHARM VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:DIEDERICK
Authorized Official - Last Name:VAN DER VELDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-500-7798
Mailing Address - Street 1:7212 U.S. HWY 31 S.
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-8549
Mailing Address - Country:US
Mailing Address - Phone:317-889-9822
Mailing Address - Fax:317-889-6500
Practice Address - Street 1:7212 US 31 S
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8549
Practice Address - Country:US
Practice Address - Phone:317-889-9822
Practice Address - Fax:317-889-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12-003283-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility