Basic Information
| Provider Information | |||||||||
| NPI: | 1982618963 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HCF OF PERRYSBURG, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE MANOR AT PERRYSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 250 MANOR DR | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435513118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198740306 | ||||||||
| FaxNumber: | 4198749295 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 MANOR DR | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435513118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198740306 | ||||||||
| FaxNumber: | 4198749295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STECHSCHULTE | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR - CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4199992010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2048N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2437974 | 05 | OH | MEDICAID | 1003318 | 01 | OH | OHIO HEALTH CHOICE INC. | OTHER | 000000317926 | 01 | OH | ANTHEM | OTHER |