Provider Demographics
NPI:1467457044
Name:PLYMOUTH NH, LLC
Entity Type:Organization
Organization Name:PLYMOUTH NH, LLC
Other - Org Name:PLYMOUTH NURSING AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-635-9500
Mailing Address - Street 1:309 N KINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1927
Mailing Address - Country:US
Mailing Address - Phone:574-936-9025
Mailing Address - Fax:574-936-4928
Practice Address - Street 1:309 N KINGSTON RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1927
Practice Address - Country:US
Practice Address - Phone:574-936-9025
Practice Address - Fax:574-936-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
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
IN15-5457Medicare ID - Type UnspecifiedMEDICARE PROVIDER