Basic Information
| Provider Information | |||||||||
| NPI: | 1013908359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONCORD CARE CENTER OF MILAN, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BRIARFIELD OF MILAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 185 S MAIN ST | ||||||||
| Address2: | P.O. BOX 1650 | ||||||||
| City: | MILAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448469765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194992576 | ||||||||
| FaxNumber: | 4194994577 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MILAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448469765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194992576 | ||||||||
| FaxNumber: | 4194994577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | IFFT | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3307592357 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 5359 | OH | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 2052095 | 05 | OH | MEDICAID | 000000314543 | 01 | OH | ANTHEM | OTHER |