Provider Demographics
NPI:1275572646
Name:THE WATERS OF YORKTOWN, LLC
Entity Type:Organization
Organization Name:THE WATERS OF YORKTOWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SORSCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-449-1900
Mailing Address - Street 1:240 FENCL LANE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-2067
Mailing Address - Country:US
Mailing Address - Phone:708-449-1900
Mailing Address - Fax:708-449-1500
Practice Address - Street 1:2000 S. ANDREWS ROAD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-6812
Practice Address - Country:US
Practice Address - Phone:765-759-7740
Practice Address - Fax:765-759-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000143-1314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100283890CMedicaid
IN000000391196OtherANTHEM ST
IN000000381429OtherANTHEM BCBS
IN000000391199OtherANTHEM OT
IN5584850001OtherDMERC REGION B SUPPLIER#
IN000000391198OtherANTHEM PT
IN000000381429OtherANTHEM BCBS
IN000000391196OtherANTHEM ST
IN5584850001OtherDMERC REGION B SUPPLIER#