MEDICARE: MSAB PARK CREEK CENTER, LLC

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	310400000X	Assisted Living Facility	2021R	OH

General Provider Information

NPI Number	:	1861718629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MSAB PARK CREEK CENTER, LLC

Provider Business Mailing Address
First Line	:	10064 N CHURCH DR
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-4066
Country	:	US
Telephone Number	:	440-842-5100
Fax Number	:	440-842-5147

Provider Business Practice Location Address
First Line	:	10064 N CHURCH DR
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-4066
Country	:	US
Telephone Number	:	440-842-5100
Fax Number	:	440-842-5147

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DAVID A. FARKAS
Credential	:
Telephone Number	:	440-842-5100

Provider Enumeration Date	:	04/19/2010
Last Update Date	:	04/19/2010

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