Provider Demographics
NPI:1598310005
Name:THE WYNDMOOR OF PORTAGE, LLC
Entity Type:Organization
Organization Name:THE WYNDMOOR OF PORTAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LACHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENKLE WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:HFA, MBA, CLSS
Authorized Official - Phone:317-258-7031
Mailing Address - Street 1:3444 SWANSON RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4999
Mailing Address - Country:US
Mailing Address - Phone:219-763-4867
Mailing Address - Fax:219-299-6570
Practice Address - Street 1:3444 SWANSON RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4999
Practice Address - Country:US
Practice Address - Phone:219-763-4867
Practice Address - Fax:219-299-6570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN19-010889-2OtherINDIANA STATE DEPARTMENT OF HEALTH RESIDENTIAL CARE LICENSE