Provider Demographics
NPI:1396863643
Name:NORMAL LIFE OF INDIANA
Entity Type:Organization
Organization Name:NORMAL LIFE OF INDIANA
Other - Org Name:BOONVILLE I
Other - Org Type:Other Name
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:OMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-394-2387
Mailing Address - Street 1:9901 LINN STATION RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3808
Mailing Address - Country:US
Mailing Address - Phone:800-866-0860
Mailing Address - Fax:
Practice Address - Street 1:118 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-1536
Practice Address - Country:US
Practice Address - Phone:812-433-3535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100234020AMedicaid