MEDICARE: CENTER RIDGE HEALTH CAMPUS

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	291U00000X	Clinical Medical Laboratory	36D0334108	OH

General Provider Information

NPI Number	:	1720232242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER RIDGE HEALTH CAMPUS

Provider Business Mailing Address
First Line	:	38600 CENTER RIDGE RD
Second Line	:
City	:	NORTH RIDGEVILLE
State	:	OH
Zip	:	44039-2837
Country	:	US
Telephone Number	:	440-327-1295
Fax Number	:

Provider Business Practice Location Address
First Line	:	38600 CENTER RIDGE RD
Second Line	:
City	:	NORTH RIDGEVILLE
State	:	OH
Zip	:	44039-2837
Country	:	US
Telephone Number	:	440-327-1295
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. JOHN T. O,NEILL
Credential	:
Telephone Number	:	440-327-9777

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/11/2008

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