1720133226 NPI number — BRADLEY ROAD NURSING HOME, INC.

Table of content: (NPI 1720133226)

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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