Basic Information
| Provider Information | |||||||||
| NPI: | 1407440118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELL PATH TENANT, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARRIAGE COURT OF KENWOOD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 S WACKER DR STE 1300 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606067466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128370701 | ||||||||
| FaxNumber: | 3128370728 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 E GALBRAITH RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452362792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134803529 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2021 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | FINIS | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5134803529 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELL PATH TENANT, LLC | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.