Basic Information
| Provider Information | |||||||||
| NPI: | 1154335305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HCF OF CRESTVIEW, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VILLAGE AT THE GREENE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4381 TONAWANDA TRL | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454301961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374265033 | ||||||||
| FaxNumber: | 9374269044 | ||||||||
| Practice Location | |||||||||
| Address1: | 4381 TONAWANDA TRL | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454301961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374265033 | ||||||||
| FaxNumber: | 9374269044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 11/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STECHSCHULTE | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR - CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4199992010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1198N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0130959 | 05 | OH | MEDICAID | 2437278 | 05 | OH | MEDICAID | 000000319322 | 01 | OH | ANTHEM | OTHER | 1003327 | 01 | OH | OHIO HEALTH CHOICE INC. | OTHER |