Basic Information
| Provider Information | |||||||||
| NPI: | 1588020218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANCREST OF ADA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W MAIN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458911761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192380715 | ||||||||
| FaxNumber: | 4192384814 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 W NORTH AVE | ||||||||
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| City: | ADA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458101041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192380715 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCLEERY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4192380715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0157521 | 05 | OH | MEDICAID |