Provider Demographics
NPI:1366256794
Name:611 W COUNTY LINE RD SOUTH TENANT LLC
Entity type:Organization
Organization Name:611 W COUNTY LINE RD SOUTH TENANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-625-4025
Mailing Address - Street 1:611 W COUNTY LINE RD S
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-7592
Mailing Address - Country:US
Mailing Address - Phone:260-625-4025
Mailing Address - Fax:
Practice Address - Street 1:611 W COUNTY LINE RD S
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-7592
Practice Address - Country:US
Practice Address - Phone:260-625-4025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility