Basic Information
Provider Information | |||||||||
NPI: | 1952879538 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHOENIX MAPLE HEIGHTS OPERATING CO., LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23925 GREENLAWN AVE | ||||||||
Address2: |   | ||||||||
City: | BEACHWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 441221434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2166301884 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19900 CLARE AVE | ||||||||
Address2: |   | ||||||||
City: | MAPLE HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441371806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2166623343 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2018 | ||||||||
LastUpdateDate: | 02/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHONFELD | ||||||||
AuthorizedOfficialFirstName: | BERNARD | ||||||||
AuthorizedOfficialMiddleName: | MOSES | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2166301884 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LNHA | ||||||||
NPICertificationDate: | 02/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.