Basic Information
Provider Information | |||||||||
NPI: | 1568456614 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DELANEY CREEK LODGE, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DELANEY CREEK LODGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 440 LAFAYETTE AVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452201022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134873600 | ||||||||
FaxNumber: | 5134873638 | ||||||||
Practice Location | |||||||||
Address1: | 320 S LAKEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335110809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136558858 | ||||||||
FaxNumber: | 8136551079 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROOKS | ||||||||
AuthorizedOfficialFirstName: | CARLA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO - DEACONESS LONG TERM CARE, INC | ||||||||
AuthorizedOfficialTelephone: | 5134873600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL9582 | FL | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | AL9582 | 01 | FL | ASSISTED LIVING LICENSE # | OTHER |