1639162316 NPI number — DEACONESS LONG TERM CARE OF OHIO, INC.

Table of content: (NPI 1639162316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639162316 NPI number — DEACONESS LONG TERM CARE OF OHIO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEACONESS LONG TERM CARE OF OHIO, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MASON HEALTH CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639162316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 ELSINORE PL STE 901
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45202-1459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-487-3600
Provider Business Mailing Address Fax Number:
513-475-4325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5640 COX SMITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45040-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-398-2881
Provider Business Practice Location Address Fax Number:
513-398-2118
Provider Enumeration Date:
08/26/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MURTA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
513-559-2265

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  5285 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 5027 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5027 . This is a "SNF LICENSE #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0129140 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5285 . This is a "RES. CARE FACILITY LIC #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".