Provider Demographics
NPI:1578093605
Name:INDIANA MASONIC HOME, INC.
Entity Type:Organization
Organization Name:INDIANA MASONIC HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-431-6170
Mailing Address - Street 1:690 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-2553
Mailing Address - Country:US
Mailing Address - Phone:317-739-0772
Mailing Address - Fax:
Practice Address - Street 1:690 S STATE ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2553
Practice Address - Country:US
Practice Address - Phone:317-739-0772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17-013621-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health