Basic Information
| Provider Information | |||||||||
| NPI: | 1003476334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARECORE AT LIMA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 599 S SHAWNEE ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192272154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 599 S SHAWNEE ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192272154 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | LAGHAIE | ||||||||
| AuthorizedOfficialFirstName: | EITAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF BUSINESS OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 4192272154 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1351 | 05 | OH | MEDICAID |