Basic Information
Provider Information | |||||||||
NPI: | 1174797328 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRONT LEASING CO LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARISTOCRAT BEREA NURSING FACILITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 ASHWOOD DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452412465 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134897100 | ||||||||
FaxNumber: | 5135301359 | ||||||||
Practice Location | |||||||||
Address1: | 255 FRONT ST | ||||||||
Address2: |   | ||||||||
City: | BEREA | ||||||||
State: | OH | ||||||||
PostalCode: | 440171943 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402434000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2008 | ||||||||
LastUpdateDate: | 04/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUMBERT | ||||||||
AuthorizedOfficialFirstName: | MONICA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | EXEC ASST TO CFO | ||||||||
AuthorizedOfficialTelephone: | 3134897100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1634N | OH | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 1634N | 01 | OH | NURSING HOME LICENSE | OTHER | 2607647 | 05 | OH |   | MEDICAID | 4625750005 | 01 | OH | DMERC | OTHER |