1720133226 NPI number — BRADLEY ROAD NURSING HOME, 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 1720133226 NPI number — BRADLEY ROAD NURSING HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY ROAD NURSING HOME, 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:
BRADLEY BAY HEALTH 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:
1720133226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34100 CENTER RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
NORTH RIDGEVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44039-5311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-327-9777
Provider Business Mailing Address Fax Number:
440-327-6172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 BRADLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY VILLAGE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44140-1670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-871-3474
Provider Business Practice Location Address Fax Number:
440-871-4743
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
O'NEILL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
440-871-3474

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  5511 , 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: 4413 , 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: 4413 . This is a "OHIO DEPT. OF HEALTH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2515148 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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