Basic Information
Provider Information | |||||||||
NPI: | 1306513239 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMBASSY LYNDHURST, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | REGENT OF LYNDHURST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25201 CHAGRIN BLVD STE 190 | ||||||||
Address2: |   | ||||||||
City: | BEACHWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 441225633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163782050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1555 BRAINARD RD | ||||||||
Address2: |   | ||||||||
City: | LYNDHURST | ||||||||
State: | OH | ||||||||
PostalCode: | 441243098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4404601000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2021 | ||||||||
LastUpdateDate: | 09/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CICCONE | ||||||||
AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2163782050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 2089R | 01 | OH | LICENSURE | OTHER |