Provider Demographics
NPI:1952463374
Name:LAFAYETTE MEDICAL INVESTORS
Entity Type:Organization
Organization Name:LAFAYETTE MEDICAL INVESTORS
Other - Org Name:HERITAGE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RAELENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:RN, HFA
Authorized Official - Phone:765-463-1541
Mailing Address - Street 1:3401 SOLDIERS HOME RD
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1222
Mailing Address - Country:US
Mailing Address - Phone:765-463-1541
Mailing Address - Fax:765-497-0687
Practice Address - Street 1:3401 SOLDIERS HOME RD
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE BRA
Practice Address - State:IN
Practice Address - Zip Code:47906-1222
Practice Address - Country:US
Practice Address - Phone:765-463-1541
Practice Address - Fax:765-497-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN313M00000X, 314000000X, 315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155402Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER