Provider Demographics
NPI:1043754229
Name:DYCORA TRANSITIONAL HEALTH - MISHAWAKA SPRINGS LLC
Entity type:Organization
Organization Name:DYCORA TRANSITIONAL HEALTH - MISHAWAKA SPRINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-277-2500
Mailing Address - Street 1:609 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2625
Mailing Address - Country:US
Mailing Address - Phone:574-277-2500
Mailing Address - Fax:
Practice Address - Street 1:609 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2625
Practice Address - Country:US
Practice Address - Phone:574-277-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility