Basic Information
Provider Information | |||||||||
NPI: | 1780795823 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RUDWICK HEALTHCARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RUDWICK MANOR SPECIAL CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26691 RICHMOND RD | ||||||||
Address2: |   | ||||||||
City: | BEDFORD HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441461421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162925706 | ||||||||
FaxNumber: | 2162922273 | ||||||||
Practice Location | |||||||||
Address1: | 17322 EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441121210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2164862280 | ||||||||
FaxNumber: | 2163834307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 03/31/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEISBERG | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | I | ||||||||
AuthorizedOfficialTitleorPosition: | ITS VP | ||||||||
AuthorizedOfficialTelephone: | 2162925706 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SABER HEALTHCARE HOLDINGS, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0318N | OH | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 2316925 | 05 | OH |   | MEDICAID |