1689771826 NPI number — CAPITAL SENIOR LIVING, ILM-B INC.

Table of content: (NPI 1689771826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689771826 NPI number — CAPITAL SENIOR LIVING, ILM-B INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL SENIOR LIVING, ILM-B 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:
CANTON REGENCY
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:
1689771826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4515 22ND ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44708-1573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-477-7664
Provider Business Mailing Address Fax Number:
330-478-9645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4515 22ND ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44708-1573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-477-7664
Provider Business Practice Location Address Fax Number:
330-478-9645
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GASPER
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
JOY
Authorized Official Title or Position:
ACCOUNTING DIRECTOR
Authorized Official Telephone Number:
330-477-7664

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  5977 , 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: 000000280669 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0005319462 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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