MEDICARE: 5040 PHILADELPHIA DRIVE OPERATING COMPANY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	1923N	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255328662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5040 PHILADELPHIA DRIVE OPERATING COMPANY INC

Provider Business Mailing Address
First Line	:	5040 PHILADELPHIA DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-3604
Country	:	US
Telephone Number	:	937-278-0404
Fax Number	:	937-278-0092

Provider Business Practice Location Address
First Line	:	5040 PHILADELPHIA DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-3604
Country	:	US
Telephone Number	:	937-278-0404
Fax Number	:	937-278-0092

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOSH HUFF
Credential	:
Telephone Number	:	937-278-0404

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	11/28/2011

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