1114918836 NPI number — KING TREE LEASING CO., LLC

Table of content: (NPI 1114918836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114918836 NPI number — KING TREE LEASING CO., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING TREE LEASING CO., LLC
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:
RIVERSIDE HEALTHCARE 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:
1114918836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 ASHWOOD DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45241-2465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-489-7100
Provider Business Mailing Address Fax Number:
513-530-1359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1390 KING TREE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45405-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-278-0723
Provider Business Practice Location Address Fax Number:
937-278-1989
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HUMBERT
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACT MANAGER
Authorized Official Telephone Number:
513-530-1622

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1649N , 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: 2530489 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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