Provider Demographics
NPI:1518342583
Name:PRISTINE SENIOR LIVING OF BEAVERCREEK, LLC
Entity Type:Organization
Organization Name:PRISTINE SENIOR LIVING OF BEAVERCREEK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-408-8491
Mailing Address - Street 1:3301 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-6356
Mailing Address - Country:US
Mailing Address - Phone:317-408-8491
Mailing Address - Fax:
Practice Address - Street 1:3854 PARK OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-5801
Practice Address - Country:US
Practice Address - Phone:937-429-9655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063595Medicaid
OH366400Medicare Oscar/Certification