Basic Information
| Provider Information | |||||||||
| NPI: | 1871693846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITEHALL LEASING CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE MANOR AT WHITEHALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5198 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441461331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168316800 | ||||||||
| FaxNumber: | 2168319734 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 LANGLEY AVE | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432136125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145018271 | ||||||||
| FaxNumber: | 6148613033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | BOWER | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2168316800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5798 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2180152 | 05 | OH | MEDICAID |