1760473961 NPI number — STOW-GLEN INC

Table of content: (NPI 1760473961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760473961 NPI number — STOW-GLEN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STOW-GLEN 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:
DASHER RETIREMENT VILLAGE
Provider Other Organization Name Type Code:
4
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:
1760473961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4285 KENT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOW
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44224-4355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-686-7100
Provider Business Mailing Address Fax Number:
330-686-7173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4285 KENT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOW
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44224-4355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-686-7100
Provider Business Practice Location Address Fax Number:
330-686-7173
Provider Enumeration Date:
11/04/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DENTON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
330-686-7170

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  1797R , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: 1797N , 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: 0580698 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1797N . This is a "NURSING HOME NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".