Basic Information
| Provider Information | |||||||||
| NPI: | 1265755755 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LAURELS OF CANTON, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LAURELS OF CANTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2714 13TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447083121 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2714 13TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447083121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147948800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1539N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3040051 | 05 | OH | MEDICAID |