Basic Information
| Provider Information | |||||||||
| NPI: | 1326022898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CIRCLEVILLE LONG TERM CARE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOGAN ELM HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7265 KENWOOD RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452364400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137938804 | ||||||||
| FaxNumber: | 5137938799 | ||||||||
| Practice Location | |||||||||
| Address1: | 370 TARLTON RD | ||||||||
| Address2: | |||||||||
| City: | CIRCLEVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431139136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404743121 | ||||||||
| FaxNumber: | 7404200418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | SCHARFENBERGER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXEC. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5137938804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LNHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3775 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0408839 | 05 | OH | MEDICAID |