1568635662 NPI number — PORTAGE TRAIL CARE CENTER INC

Table of content: (NPI 1568635662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568635662 NPI number — PORTAGE TRAIL CARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTAGE TRAIL CARE CENTER 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:
TRADITIONS 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:
1568635662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2335 N BANK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43220-5423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-451-2151
Provider Business Mailing Address Fax Number:
614-451-0351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E BATH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUYAHOGA FALLS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44223-2510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-929-6272
Provider Business Practice Location Address Fax Number:
330-922-4059
Provider Enumeration Date:
04/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NADERHOFF
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
614-451-2151

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , 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)