Basic Information
| Provider Information | |||||||||
| NPI: | 1063741445 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NILES SKILLED NURSING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AUTUMN HILLS CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7261 ENGLE RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441308467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167721105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2565 NILES VIENNA RD | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444464401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306522053 | ||||||||
| FaxNumber: | 3306520112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2009 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARSONS | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2167721105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1847N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1847N | 01 | OH | LICENSE NUMBER | OTHER | 3006606 | 05 | OH | MEDICAID |