Provider Demographics
NPI:1619371986
Name:REAGAN PARK SENIOR LIVING LLC
Entity Type:Organization
Organization Name:REAGAN PARK SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH FACILITY ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-271-0100
Mailing Address - Street 1:1176 KINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-5501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1176 KINGWOOD DR
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-5501
Practice Address - Country:US
Practice Address - Phone:317-271-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN140132642310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility