Basic Information
| Provider Information | |||||||||
| NPI: | 1538667829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 17TH ST LEASING CO LLC | ||||||||
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| OtherOrganizationName: | THE PINES HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 ASHWOOD DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452412424 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3015 17TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447086004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304546508 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2018 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | STOLTZ | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135301613 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.