Basic Information
| Provider Information | |||||||||
| NPI: | 1659689859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLER HOLDINGS TAKODA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AFFINITY PLACE HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 ELM RD NE | ||||||||
| Address2: | STE 600 | ||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444832900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303076816 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7750 AFFINITY PLACE | ||||||||
| Address2: | |||||||||
| City: | MT. HEALTHY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132570344 | ||||||||
| FaxNumber: | 5135213100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2010 | ||||||||
| LastUpdateDate: | 12/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3303076816 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 0072252 | 05 | OH | MEDICAID |