Basic Information
| Provider Information | |||||||||
| NPI: | 1962447037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH CARE AND RETIREMENT CORPORATION OF AMERICA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEARTLAND OF CHARLESTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | ATTN: BARRY LAZARUS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525541 | ||||||||
| FaxNumber: | 4192525548 | ||||||||
| Practice Location | |||||||||
| Address1: | 3819 CHESTERFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253042647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049254771 | ||||||||
| FaxNumber: | 3049251343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | LAZARUS | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - REIMBURSEMENTS | ||||||||
| AuthorizedOfficialTelephone: | 4192525541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 65 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0003744002 | 05 | WV | MEDICAID |