Basic Information
| Provider Information | |||||||||
| NPI: | 1750468237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPRINGFIELD HEALTH CARE OPERATING COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPRINGFIELD MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2457 BROADWAY AVENUE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404397976 | ||||||||
| FaxNumber: | 4402327113 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 E. MCCREIGHT AVE. | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373998311 | ||||||||
| FaxNumber: | 9373997370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | BARTLEBAUGH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3304254696 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 1044N | OH | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 1044N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0391204 | 05 | OH | MEDICAID |