Basic Information
| Provider Information | |||||||||
| NPI: | 1720583578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE LAURELS OF GAHANNA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LAURELS OF GAHANNA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8181 WORTHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430828067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147948800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5151 N HAMILTON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143371066 | ||||||||
| FaxNumber: | 6143374039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1930N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0292331 | 05 | OH | MEDICAID |