| Organization Name: | COUNTRY CHARM VILLAGE LLC |
| NPI Number: | 1225397011 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | C. DIEDERICK VAN DER VELDE (PRESIDENT) |
| Mailing Address: | 7212 Us 31 S Indianapolis |
| State: | IN US |
| Postal Code: | 462278549 |
| Phone Number: | 3178899822 |
| Fax Number: | 3178896500 |
| NPI Enumeration Date: | 05/14/2012 |
| NPI Last Update Date: | 05/14/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 310400000X |
| License Number: | 12-003283-1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Nursing & Custodial Care Facilities |
| Taxonomy Classification: | Assisted Living Facility |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being. |