1891860656 NPI number — CLEVELAND NURSING AND REHABILITATION CENTER, LLC

Table of content: (NPI 1891860656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891860656 NPI number — CLEVELAND NURSING AND REHABILITATION CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEVELAND NURSING AND REHABILITATION CENTER, 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:
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:
1891860656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-662-4955
Provider Business Mailing Address Fax Number:
716-667-9230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4036 HIGHWAY 8 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-843-4014
Provider Business Practice Location Address Fax Number:
662-843-5401
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
NORBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CO-CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
716-662-4955

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  380 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05621394 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005621394 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000080386 . This is a "BC BS OF MISSISSIPPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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