Basic Information
| Provider Information | |||||||||
| NPI: | 1972023844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARDINAL GAHANNA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CREEKSIDE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6967 DEER TRAIL AVE NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447212069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309367158 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5151 N HAMILTON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432301313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143371066 | ||||||||
| FaxNumber: | 6143371013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2017 | ||||||||
| LastUpdateDate: | 06/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | ALTIERI | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3309367158 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1930N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.