Basic Information
| Provider Information | |||||||||
| NPI: | 1659316586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANOR CARE OF WILLOUGHBY OH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA SKILLED NURSING AND REHABILITATION (WILLOUGHBY) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525734 | ||||||||
| FaxNumber: | 8773859446 | ||||||||
| Practice Location | |||||||||
| Address1: | 37603 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440945923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409515551 | ||||||||
| FaxNumber: | 4409511914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1556N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2792312 | 05 | OH | MEDICAID |