Basic Information
| Provider Information | |||||||||
| NPI: | 1861689465 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EARLEY & ROSS OF FAYETTE COUNTY L,LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WINTERSONG VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 719 RAWLINGS ST | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431601517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403351380 | ||||||||
| FaxNumber: | 7406360643 | ||||||||
| Practice Location | |||||||||
| Address1: | 719 RAWLINGS ST | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431601517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403351380 | ||||||||
| FaxNumber: | 7406360643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7403351380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2768189 | 05 | OH | MEDICAID | 1861689465 | 01 | OH | FACILITY NPI | OTHER | 366262 | 01 | OH | MEDICARE PROVIDER NUMBER | OTHER |