Provider Demographics
NPI:1578631073
Name:SALEM VILLAGES MRDD, INC.
Entity Type:Organization
Organization Name:SALEM VILLAGES MRDD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:OMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-394-2387
Mailing Address - Street 1:10140 LINN STATION RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3813
Mailing Address - Country:US
Mailing Address - Phone:800-866-0860
Mailing Address - Fax:
Practice Address - Street 1:27566 SUFFRIDGE DR
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4527
Practice Address - Country:US
Practice Address - Phone:352-372-0130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL028054200Medicaid