Provider Demographics
NPI:1942348198
Name:GOODMAN LOSTUTTER LLC
Entity Type:Organization
Organization Name:GOODMAN LOSTUTTER LLC
Other - Org Name:PINE KNOLL ASSISTED LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:POE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-537-4422
Mailing Address - Street 1:607 WILSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-1074
Mailing Address - Country:US
Mailing Address - Phone:812-537-4422
Mailing Address - Fax:
Practice Address - Street 1:607 WILSON CREEK RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1074
Practice Address - Country:US
Practice Address - Phone:812-537-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060011421302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization