MEDICARE: WOODLANDS ASSISTED LIVING RESIDENCE-EASTLAND

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	305R00000X	Preferred Provider Organization	2072R	OH

General Provider Information

NPI Number	:	1275911992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODLANDS ASSISTED LIVING RESIDENCE-EASTLAND

Provider Business Mailing Address
First Line	:	2469 KIMBERLY PKWY E
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4273
Country	:	US
Telephone Number	:	614-866-2080
Fax Number	:

Provider Business Practice Location Address
First Line	:	2469 KIMBERLY PKWY E
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4273
Country	:	US
Telephone Number	:	614-866-2080
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. RICHARD M OSBORNE JR.
Credential	:
Telephone Number	:	216-219-0290

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	05/14/2015

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