Basic Information
| Provider Information | |||||||||
| NPI: | 1386880284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMBASSY BROADWAY MANAGEMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24579 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441466338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404397976 | ||||||||
| FaxNumber: | 4402327113 | ||||||||
| Practice Location | |||||||||
| Address1: | 16231 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441372526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166620551 | ||||||||
| FaxNumber: | 2166627754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | HAYLEY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 2164796419 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1867N | OH | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 2739611 | 05 | OH | MEDICAID |