Provider Demographics
NPI:1750585766
Name:GOSPORT CARE, INC.
Entity type:Organization
Organization Name:GOSPORT CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:PONTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-879-4242
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:GOSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47433-0099
Mailing Address - Country:US
Mailing Address - Phone:812-879-4242
Mailing Address - Fax:812-879-4633
Practice Address - Street 1:27 S. 7TH ST.
Practice Address - Street 2:
Practice Address - City:GOSPORT
Practice Address - State:IN
Practice Address - Zip Code:47433-0099
Practice Address - Country:US
Practice Address - Phone:812-879-4242
Practice Address - Fax:812-879-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000409-1313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15E281Medicaid