Provider Demographics
NPI:1942559745
Name:INDYWOOD ESTATE, LLC
Entity Type:Organization
Organization Name:INDYWOOD ESTATE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-455-3878
Mailing Address - Street 1:1416 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2103
Mailing Address - Country:US
Mailing Address - Phone:662-455-3878
Mailing Address - Fax:662-455-6171
Practice Address - Street 1:218 RONALDMAN RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-8755
Practice Address - Country:US
Practice Address - Phone:662-843-7885
Practice Address - Fax:662-843-7985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS960310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00037512Medicaid