Provider Demographics
NPI:1982000964
Name:GUMBO LLC
Entity Type:Organization
Organization Name:GUMBO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:269-240-7881
Mailing Address - Street 1:2618 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2618 RIVER AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1568
Practice Address - Country:US
Practice Address - Phone:269-240-7881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28188157A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility