Basic Information
| Provider Information | |||||||||
| NPI: | 1780676205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIAMI SHORES OF MORAINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 PINNACLE RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454182918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372683488 | ||||||||
| FaxNumber: | 9372675021 | ||||||||
| Practice Location | |||||||||
| Address1: | 3421 PINNACLE RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454182918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372683488 | ||||||||
| FaxNumber: | 9372675021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 02/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEERMANS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9372683488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1723-NH | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2358112 | 05 | OH | MEDICAID |