Basic Information
| Provider Information | |||||||||
| NPI: | 1609089135 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MELLON RIDGE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MELLON RIDGE RESIDENTIAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22021 BROOKPARK RD | ||||||||
| Address2: | STE 123 | ||||||||
| City: | FAIRVIEW PARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441263100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406140160 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Practice Location | |||||||||
| Address1: | 1659 STATE ROUTE 28 | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451229705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135755052 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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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 | 310400000X | 2036 | OH | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.