Basic Information
| Provider Information | |||||||||
| NPI: | 1538245790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 60 GENEVA HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GENEVA POINTE SKILLED NURSING & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 22021 BROOKPARK RD | ||||||||
| Address2: | STE 123 | ||||||||
| City: | FAIRVIEW PARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441263100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406140160 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 WEST ST | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440419723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404661181 | ||||||||
| FaxNumber: | 4404669165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLLERAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4406140160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1659 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2691547 | 05 | OH | MEDICAID |