Basic Information
| Provider Information | |||||||||
| NPI: | 1497759849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELIZA JENNINGS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTH CENTER AT RENAISSANCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26376 JOHN RD | ||||||||
| Address2: | |||||||||
| City: | OLMSTED FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441381277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402357100 | ||||||||
| FaxNumber: | 4402357115 | ||||||||
| Practice Location | |||||||||
| Address1: | 26376 JOHN RD | ||||||||
| Address2: | |||||||||
| City: | OLMSTED FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441381277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402357100 | ||||||||
| FaxNumber: | 4402357115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOFFATTE | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4402357100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LNHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4116 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0840068 | 05 | OH | MEDICAID |