Provider Demographics
NPI:1992196638
Name:INDIANA MASONIC HOME, INC.
Entity Type:Organization
Organization Name:INDIANA MASONIC HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:812-314-8247
Mailing Address - Street 1:690 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-2553
Mailing Address - Country:US
Mailing Address - Phone:812-314-8247
Mailing Address - Fax:
Practice Address - Street 1:690 S STATE ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2553
Practice Address - Country:US
Practice Address - Phone:812-314-8247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA MASONIC HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15-013621-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201300160AMedicaid