Basic Information
Provider Information | |||||||||
NPI: | 1154516581 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELYRIA LARGE GROUP HOMES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PALM CREST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25000 COUNTRY CLUB BLVD | ||||||||
Address2: | STE 255 | ||||||||
City: | NORTH OLMSTED | ||||||||
State: | OH | ||||||||
PostalCode: | 440705344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4406140160 | ||||||||
FaxNumber: | 4406140168 | ||||||||
Practice Location | |||||||||
Address1: | 1251 EAST AVE | ||||||||
Address2: |   | ||||||||
City: | ELYRIA | ||||||||
State: | OH | ||||||||
PostalCode: | 440357674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403220726 | ||||||||
FaxNumber: | 4403222810 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2007 | ||||||||
LastUpdateDate: | 08/06/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLLERAN | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4406140160 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X |   | OH | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
ID Information
ID | Type | State | Issuer | Description | 2940410 | 05 | OH |   | MEDICAID |