Basic Information
Provider Information | |||||||||
NPI: | 1629264379 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEREGRINE SERVICES OF CANTON, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUMMIT'STRACE OF CANTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1661 OLD HENDERSON RD | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432203644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144592656 | ||||||||
FaxNumber: | 6144592641 | ||||||||
Practice Location | |||||||||
Address1: | 836 34TH ST NW | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447092947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144592482 | ||||||||
FaxNumber: | 6144592641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2007 | ||||||||
LastUpdateDate: | 11/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAUERMAN | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6144592656 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 2771095 | 05 | OH |   | MEDICAID |