Basic Information
| Provider Information | |||||||||
| NPI: | 1427437698 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 17322 EUCLID AVENUE COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RUDWICK MANOR SPECIAL CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17322 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441121210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164862280 | ||||||||
| FaxNumber: | 2163834307 | ||||||||
| Practice Location | |||||||||
| Address1: | 17322 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441121210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164862280 | ||||||||
| FaxNumber: | 2163834307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | HAYLEY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 2167063936 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0318N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.