Basic Information
| Provider Information | |||||||||
| NPI: | 1568446862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHS - LAKE ERIE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRYDEN PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25000 COUNTRY CLUB BLVD | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440705344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406140160 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Practice Location | |||||||||
| Address1: | 1169 BRYDEN RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432051928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142586623 | ||||||||
| FaxNumber: | 6142588171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 03/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | COLLERAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4406140160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 6254 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2339599 | 05 | OH | MEDICAID |