Basic Information
| Provider Information | |||||||||
| NPI: | 1174688287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENERATION HEALTH & REHABILITATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | FLINT RIDGE NURSING AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 W. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430553653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403481300 | ||||||||
| FaxNumber: | 7403443091 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 W. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430553653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403481300 | ||||||||
| FaxNumber: | 7403443091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7403481389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1489N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2390523 | 05 | OH | MEDICAID |