1598828907 NPI number — SNF WADSWORTH LLC

Table of content: (NPI 1598828907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598828907 NPI number — SNF WADSWORTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNF WADSWORTH 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:
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:
1598828907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5625 EMERALD RIDGE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOLON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44139-1860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-498-3000
Provider Business Mailing Address Fax Number:
440-498-8257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 GREAT OAKS TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WADSWORTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44281-8799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-336-3472
Provider Business Practice Location Address Fax Number:
330-334-2026
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCMAHAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
440-498-3000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2350N , 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: 2319717 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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