Provider Demographics
NPI:1437159134
Name:SHADY NOOK NURSING HOME, INC
Entity Type:Organization
Organization Name:SHADY NOOK NURSING HOME, INC
Other - Org Name:SHADY NOOK CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-537-0930
Mailing Address - Street 1:36 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-1084
Mailing Address - Country:US
Mailing Address - Phone:812-537-0930
Mailing Address - Fax:812-537-0326
Practice Address - Street 1:36 VALLEY DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1084
Practice Address - Country:US
Practice Address - Phone:812-537-0930
Practice Address - Fax:812-537-0326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155525Medicare ID - Type Unspecified