Basic Information
| Provider Information | |||||||||
| NPI: | 1194729038 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOW PARK CONVALESCENT HOME,INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18810 HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167523600 | ||||||||
| FaxNumber: | 2167525612 | ||||||||
| Practice Location | |||||||||
| Address1: | 18810 HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167523600 | ||||||||
| FaxNumber: | 2167525612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | AR MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6144162638 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4104 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2402519 | 05 | OH | MEDICAID |