Basic Information
| Provider Information | |||||||||
| NPI: | 1578519500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LAURELS OF CHARLOTTESVILLE, LLC | ||||||||
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| OtherOrganizationName: | THE LAURELS OF CHARLOTTESVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8181 WORTHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430828067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147948800 | ||||||||
| FaxNumber: | 6147948826 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 HILLSDALE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229015731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349514200 | ||||||||
| FaxNumber: | 4349514201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NH2754 | VA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NH2754 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 010098513 | 05 | VA | MEDICAID | NH2754 | 01 | VA | NURSING HOME LICENSE # | OTHER |