Provider Demographics
NPI:1407927098
Name:VINCENNES OPERATOR, LLC
Entity Type:Organization
Organization Name:VINCENNES OPERATOR, LLC
Other - Org Name:CRESTVIEW HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:TSCHUDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-429-8062
Mailing Address - Street 1:7400 NEW LAGRANGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-429-8062
Mailing Address - Fax:502-429-5980
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:BOX 216
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-882-1783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6295314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155042Medicare ID - Type Unspecified