Basic Information
| Provider Information | |||||||||
| NPI: | 1760583272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESSEX HEALTHCARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERGREEN MANOR NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EASTON OVAL | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432196061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144162662 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 924 CHARLIES WAY | ||||||||
| Address2: | |||||||||
| City: | MONTPELIER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435431904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194858307 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | YODER | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6144162662 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1513N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2033758 | 05 | OH | MEDICAID |