Basic Information
| Provider Information | |||||||||
| NPI: | 1528294782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEREGRINE HEALTH SERVICES OF CINCINNATI, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OAK PAVILION NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 OLD HENDERSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432203644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144592482 | ||||||||
| FaxNumber: | 6144592641 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 OAK ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137510880 | ||||||||
| FaxNumber: | 5137510882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 07/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | ALEMAN | ||||||||
| AuthorizedOfficialFirstName: | OSCAR | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6144592482 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1570N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2945933 | 05 | OH | MEDICAID |