Provider Demographics
NPI:1265463665
Name:HICKORY CREEK HEALTHCARE FOUNDATION, INC.
Entity Type:Organization
Organization Name:HICKORY CREEK HEALTHCARE FOUNDATION, INC.
Other - Org Name:HICKORY CREEK AT GASTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:WAYMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-570-0266
Mailing Address - Street 1:6081 E 82ND ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1795
Mailing Address - Country:US
Mailing Address - Phone:317-570-0266
Mailing Address - Fax:317-570-0488
Practice Address - Street 1:502 N. MADISON ST
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:IN
Practice Address - Zip Code:47342-0159
Practice Address - Country:US
Practice Address - Phone:765-358-3324
Practice Address - Fax:765-358-4365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HICKORY CREEK HEALTHCARE FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000614-1315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100272120Medicaid