Basic Information
| Provider Information | |||||||||
| NPI: | 1427081629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENDALE PLACE CARE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 779 GLENDALE MILFORD RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452151161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137711779 | ||||||||
| FaxNumber: | 5137714799 | ||||||||
| Practice Location | |||||||||
| Address1: | 779 GLENDALE MILFORD RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452151161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137711779 | ||||||||
| FaxNumber: | 5137714799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 09/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | KOHN | ||||||||
| AuthorizedOfficialFirstName: | CHASE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5137711779 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2450N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2675645 | 05 | OH | MEDICAID |