Basic Information
Provider Information | |||||||||
NPI: | 1902880131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHS - MIAMI VALLEY, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRANKLIN RIDGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8200 BECKETT PARK DR | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | OH | ||||||||
PostalCode: | 450118955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5136822700 | ||||||||
FaxNumber: | 5136822716 | ||||||||
Practice Location | |||||||||
Address1: | 421 MISSION LN | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 450052327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9377463943 | ||||||||
FaxNumber: | 9377469126 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICE | ||||||||
AuthorizedOfficialFirstName: | WANDA | ||||||||
AuthorizedOfficialMiddleName: | JEAN | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5136822700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 6237 | OH | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 2339688 | 05 | OH |   | MEDICAID |