Provider Demographics
NPI:1356336861
Name:AMBASSADOR HEALTHCARE, LLC
Entity type:Organization
Organization Name:AMBASSADOR HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:K.
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-577-4150
Mailing Address - Street 1:12953 PUBLISHERS DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-8811
Mailing Address - Country:US
Mailing Address - Phone:317-577-2827
Mailing Address - Fax:317-577-5933
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IN
Practice Address - Zip Code:47330-9676
Practice Address - Country:US
Practice Address - Phone:765-855-3424
Practice Address - Fax:765-855-1087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050004561314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000315404OtherBC/BS PROVIDER NUMBER
IN000000315404OtherBC/BS PROVIDER NUMBER
IN15-5490Medicare ID - Type Unspecified