Basic Information
| Provider Information | |||||||||
| NPI: | 1457848210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CT OHIO PORTSMOUTH LLC | ||||||||
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| OtherOrganizationName: | PORTSMOUTH HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 GLENLAKE PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303287246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704565822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 727 8TH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403548150 | ||||||||
| FaxNumber: | 7403531826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUBENSTEIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7704565822 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 141343 | 05 | OH | MEDICAID |