Basic Information
| Provider Information | |||||||||
| NPI: | 1043203722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS LONG TERM CARE OF OHIO, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONVOY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 LAFAYETTE AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452201022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134873600 | ||||||||
| FaxNumber: | 5134873653 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 MENTZER DR | ||||||||
| Address2: | |||||||||
| City: | CONVOY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197492194 | ||||||||
| FaxNumber: | 4197492424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5134873600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1767N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0214771 | 05 | OH | MEDICAID |