Healthcare Provider Details

I. General information

NPI: 1326154527
Provider Name (Legal Business Name): HARBORSIDE OF CLEVELAND LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK EAST DR
BEACHWOOD OH
44122-4316
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 216-831-4303
  • Fax: 216-831-1032
Mailing address:
  • Phone: 505-468-4742
  • Fax: 505-468-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5148
License Number StateOH

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4742