Provider Demographics
NPI:1629831110
Name:EMBOLDEN SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EMBOLDEN SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-744-0687
Mailing Address - Street 1:9701 E MILLER ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:IN
Mailing Address - Zip Code:47383-9630
Mailing Address - Country:US
Mailing Address - Phone:765-744-0687
Mailing Address - Fax:
Practice Address - Street 1:607 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3847
Practice Address - Country:US
Practice Address - Phone:812-273-0432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility