1013173129 NPI number — PROMEDICA CONTINUING CARE SERVICES CORP.

Table of content: (NPI 1013173129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013173129 NPI number — PROMEDICA CONTINUING CARE SERVICES CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMEDICA CONTINUING CARE SERVICES CORP.
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:
Provider Other Organization Name Type Code:
6
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:
1013173129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4345 SECOR RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43623-4233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-8240
Provider Business Mailing Address Fax Number:
419-480-1268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2142 N COVE BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-3895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-6840
Provider Business Practice Location Address Fax Number:
419-480-8711
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
GLADEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
419-469-3780

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 179937 . This is a "VENDOR LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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