Basic Information
| Provider Information | |||||||||
| NPI: | 1780750679 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHCARE VENTURES OF OHIO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRIDERSVILLE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 OLD HENDERSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432203644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144592482 | ||||||||
| FaxNumber: | 6144592641 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CRIDERSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458062454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196454468 | ||||||||
| FaxNumber: | 4196454648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | ALEMAN | ||||||||
| AuthorizedOfficialFirstName: | OSCAR | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6144592482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1580N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2561393 | 05 | OH | MEDICAID |