Basic Information
| Provider Information | |||||||||
| NPI: | 1730493727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BCC MEDINA OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELMCROFT OF MEDINA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9510 ORMSBY STATION RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402234081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027536004 | ||||||||
| FaxNumber: | 5027536104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1046 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442561102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307212000 | ||||||||
| FaxNumber: | 3307230742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2010 | ||||||||
| LastUpdateDate: | 08/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AND SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5027536004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | ESQ. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | 2227R | OH | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 2227R | 01 | OH | RESIDENTIAL CARE FACILITY LICENSE | OTHER |