Provider Demographics
NPI:1740214493
Name:HICKORY CREEK HEALTHCARE FOUNDATION, INC.
Entity Type:Organization
Organization Name:HICKORY CREEK HEALTHCARE FOUNDATION, INC.
Other - Org Name:HICKORY CREEK AT LEBANON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:WAYMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-570-0266
Mailing Address - Street 1:1585 PERRY WORTH RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-9635
Mailing Address - Country:US
Mailing Address - Phone:765-482-6391
Mailing Address - Fax:765-483-2590
Practice Address - Street 1:1585 PERRY WORTH RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-9635
Practice Address - Country:US
Practice Address - Phone:765-482-6391
Practice Address - Fax:765-483-2590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155211Medicare ID - Type Unspecified