Provider Demographics
NPI:1972637171
Name:SOUTHLAKE TRICITY RBA
Entity type:Organization
Organization Name:SOUTHLAKE TRICITY RBA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:KRUMWIED
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:219-392-6010
Mailing Address - Street 1:2075 RIPLEY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-1161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2075 RIPLEY ST
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-1161
Practice Address - Country:US
Practice Address - Phone:219-962-9437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility