Provider Demographics
NPI:1871707737
Name:INDIANA MASONIC HOME, INC.
Entity type:Organization
Organization Name:INDIANA MASONIC HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LIMEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-736-6141
Mailing Address - Street 1:690 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-2591
Mailing Address - Country:US
Mailing Address - Phone:317-736-6141
Mailing Address - Fax:317-736-0454
Practice Address - Street 1:690 STATE STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2591
Practice Address - Country:US
Practice Address - Phone:317-736-6141
Practice Address - Fax:317-736-0454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANA MASONIC HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-10
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN070011331251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000590734OtherANTHEM
IN000000590734OtherANTHEM