Basic Information
| Provider Information | |||||||||
| NPI: | 1841551488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHG WHITEHALL HOLDINGS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26691 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441461421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162925706 | ||||||||
| FaxNumber: | 2162922273 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 LANGLEY AVE | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432136125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145018271 | ||||||||
| FaxNumber: | 6148613033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEISBERG | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | I. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2162925706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SABER HEALTHCARE HOLDINGS, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2288N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0071458 | 05 | OH | MEDICAID |