Provider Demographics
NPI:1881631240
Name:THE WATERS OF DUNELAND, LLC
Entity Type:Organization
Organization Name:THE WATERS OF DUNELAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLISKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-449-1900
Mailing Address - Street 1:110 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9368
Mailing Address - Country:US
Mailing Address - Phone:219-926-8387
Mailing Address - Fax:219-395-1510
Practice Address - Street 1:110 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9368
Practice Address - Country:US
Practice Address - Phone:219-926-8387
Practice Address - Fax:219-929-1776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-000150-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000476402OtherANTHEM OT
IN000000381420OtherANTHEM BCBS
IN000000476404OtherANTHEM ST
IN000000476403OtherANTHEM PT
IN5584660001OtherDMERC REGION B SUPPLIER#
IN100267000CMedicaid
IN5584660001OtherDMERC REGION B SUPPLIER#
IN100267000CMedicaid