Basic Information
| Provider Information | |||||||||
| NPI: | 1073634788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHS - PATASKALA, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | TUSCANY GARDENS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6967 DEER TRAIL AVE NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447212069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309367158 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7400 HAZELTON-ETNA ROAD | ||||||||
| Address2: | |||||||||
| City: | PATASKALA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409640803 | ||||||||
| FaxNumber: | 7409640804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | ALTIERI | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3309367158 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 2758412 | 05 | OH | MEDICAID |