Basic Information
| Provider Information | |||||||||
| NPI: | 1386029155 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRISTINE SENIOR LIVING OF DAYTON-CENTERVILLE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W PURDUE AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473046356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174088491 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7300 MCEWEN RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454593903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374333441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3174088491 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2335146 | 05 | OH | MEDICAID |