1205881661 NPI number — THE LAURELS OF ROCKFORD, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205881661 NPI number — THE LAURELS OF ROCKFORD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE LAURELS OF ROCKFORD, 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:
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:
1205881661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8181 WORTHINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43082-8067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-794-8800
Provider Business Mailing Address Fax Number:
614-794-8826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10731 STATE ROUTE 118
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45882-8947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-363-2620
Provider Business Practice Location Address Fax Number:
419-363-2354
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
ANIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
614-794-8800

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  1492N , 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: 1492N , 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: 2165286 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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