Basic Information
| Provider Information | |||||||||
| NPI: | 1104999846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHCARE VENTURES OF OHIO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CONVALARIUM AT INDIAN RUM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 OLD HENDERSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432203644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144592482 | ||||||||
| FaxNumber: | 6144592641 | ||||||||
| Practice Location | |||||||||
| Address1: | 6430 POST RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430161226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147611188 | ||||||||
| FaxNumber: | 6147610410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 03/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | ALEMAN | ||||||||
| AuthorizedOfficialFirstName: | OSCAR | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6144592482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1900N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2561384 | 05 | OH | MEDICAID |