Basic Information
| Provider Information | |||||||||
| NPI: | 1043836471 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCREA OPERATING COMPANY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 OLD HENDERSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432203644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144590445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2040 MCCREA ST | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446012703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308239005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2020 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAZELBAKER | ||||||||
| AuthorizedOfficialFirstName: | R. | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARTY | ||||||||
| AuthorizedOfficialTelephone: | 9494993311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1804N | 01 | OH | LICENSURE | OTHER |