Basic Information
| Provider Information | |||||||||
| NPI: | 1215143417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED HEALTH SERVICES OF NEW LONDON AT FIRELANDS | ||||||||
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| OtherOrganizationName: | NEW LONDON HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1680 MICHIGAN AVE | ||||||||
| Address2: | SUITE 736 | ||||||||
| City: | MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331392538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058921790 | ||||||||
| FaxNumber: | 3055382699 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448511070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058921790 | ||||||||
| FaxNumber: | 3055382699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DUAY | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3058921790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1825N | OH | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 0590810 | 05 | OH | MEDICAID |