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NPI Code Detail

MEDICARE: GLENDORA DIVINE OPCO LLC

MEDICARE: GLENDORA DIVINE OPCO 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1942098744
Entity Type Code : Organization
Provider Name (Legal Business Name) : GLENDORA DIVINE OPCO LLC
Provider Business Mailing Address
First Line : 5915 LANDERBROOK DR STE 350
Second Line :
City : MAYFIELD HEIGHTS
State : OH
Zip : 44124-4063
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1552 N HONEYTOWN RD
Second Line :
City : WOOSTER
State : OH
Zip : 44691-9511
Country : US
Telephone Number : 330-620-7828
Fax Number :
Authorized Official
Title or Position : VP OF OPERATIONS
Name : JEFFREY DEGYANKSY
Credential :
Telephone Number : 330-620-7828
Provider Enumeration Date : 04/30/2025
Last Update Date : 04/30/2025

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Directions to “GLENDORA DIVINE OPCO LLC ” Practice Location

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