Basic Information
Provider Information | |||||||||
NPI: | 1427422088 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MINERAL RIDGE SKILLED NURSING AND RESIDENTIAL CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7261 ENGLE RD | ||||||||
Address2: | STE 200 | ||||||||
City: | MIDDLEBURG HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441308467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3379 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MINERAL RIDGE | ||||||||
State: | OH | ||||||||
PostalCode: | 444409735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2167721105 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2015 | ||||||||
LastUpdateDate: | 11/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARSONS | ||||||||
AuthorizedOfficialFirstName: | BENJAMINJ | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 2167723192 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.