Basic Information
| Provider Information | |||||||||
| NPI: | 1841770740 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 920 SOUTH MAIN STREET OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW LEXINGTON CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW LEXINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437641552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW LEXINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437641552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT CARE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.