Organization
WHITE RIVER LODGE, LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BRENDA PREMO (ADMINISTRATOR)
(812) 275-7006
Entity
Organization
Contact information
Practice address
3710 KENNY SIMPSON LN, BEDFORD, IN 47421-5632
(812) 275-7006
Mailing address
3710 KENNY SIMPSON LN, BEDFORD, IN 47421-5632
(812) 275-7006
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
4843
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200155900A
—
IN
Enumeration date
05/23/2007
Last updated
01/06/2012
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