Basic Information
| Provider Information | |||||||||
| NPI: | 1588645667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDLAND LEASING CO., LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CRESTWOOD CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4700 ASHWOOD DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452412465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134897100 | ||||||||
| FaxNumber: | 5135301359 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448751412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193471266 | ||||||||
| FaxNumber: | 4193427035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUBBARD | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF A/R | ||||||||
| AuthorizedOfficialTelephone: | 5135301327 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1491 | OH | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 2424782 | 05 | OH | MEDICAID |