Provider Demographics
NPI:1346356805
Name:INDIAN CREEK HEALTH CARE INC.
Entity Type:Organization
Organization Name:INDIAN CREEK HEALTH CARE INC.
Other - Org Name:EDISON MANOR NURSING AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-292-5706
Mailing Address - Street 1:23700 COMMERCE PARK
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5827
Mailing Address - Country:US
Mailing Address - Phone:216-292-5706
Mailing Address - Fax:
Practice Address - Street 1:222 W EDISON AVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-2174
Practice Address - Country:US
Practice Address - Phone:724-652-6340
Practice Address - Fax:724-656-1170
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SABER HEALTHCARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA025902314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012046610001Medicaid
39-5536Medicare ID - Type Unspecified