1568491694 NPI number — LIBERTY NURSING CENTER OF MANSFIELD, 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 1568491694 NPI number — LIBERTY NURSING CENTER OF MANSFIELD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY NURSING CENTER OF MANSFIELD, 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:
1568491694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7445 LIBERTY WOODS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-3911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-296-1550
Provider Business Mailing Address Fax Number:
937-296-1540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 LEXINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44907-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-756-7111
Provider Business Practice Location Address Fax Number:
419-774-9055
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK-KUREK
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
937-296-1550

Provider Taxonomy Codes

  • Taxonomy code: 3140N1450X , with the licence number:  1447N , 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: 2411929 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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