Basic Information
| Provider Information | |||||||||
| NPI: | 1164471520 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE SARAH JANE LIVING CENTER, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VANCREST OF CONVOY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458911761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192380715 | ||||||||
| FaxNumber: | 4192384814 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 E TULLY ST | ||||||||
| Address2: | |||||||||
| City: | CONVOY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458328876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197492194 | ||||||||
| FaxNumber: | 4197492424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCLEERY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4192380715 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5117 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.