Provider Demographics
NPI:1851899603
Name:INDIANA LEASING CO., LLC
Entity Type:Organization
Organization Name:INDIANA LEASING CO., LLC
Other - Org Name:GRANDE LAKE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-530-1613
Mailing Address - Street 1:4700 ASHWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1209 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-1310
Practice Address - Country:US
Practice Address - Phone:419-394-7611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility