Basic Information
Provider Information | |||||||||
NPI: | 1346745197 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE LAURELS OF HAMILTON, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE LAURELS OF HAMILTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8181 WORTHINGTON RD | ||||||||
Address2: |   | ||||||||
City: | WESTERVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 430828067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6147948800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2923 HAMILTON MASON ROAD | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | OH | ||||||||
PostalCode: | 45011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138630360 | ||||||||
FaxNumber: | 5138511890 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2018 | ||||||||
LastUpdateDate: | 07/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KHAN | ||||||||
AuthorizedOfficialFirstName: | ANIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
AuthorizedOfficialTelephone: | 6147948800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0776N | OH | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0292821 | 05 | OH |   | MEDICAID |