Basic Information
| Provider Information | |||||||||
| NPI: | 1154419869 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOCUST RIDGE NURSING HOME INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12745 ELM CORNER RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451769621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374442920 | ||||||||
| FaxNumber: | 9374441009 | ||||||||
| Practice Location | |||||||||
| Address1: | 12745 ELM CORNER RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451769621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374442920 | ||||||||
| FaxNumber: | 9374441009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MEEKER | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BOARD OF DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5137975144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | 0771N | OH | X | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 313M00000X | 0771N | OH | X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 0771N | OH | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0071952 | 05 | OH | MEDICAID |