Healthcare Provider Details

I. General information

NPI: 1508865767
Provider Name (Legal Business Name): GASLITE VILLA CONVALESCENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7055 HIGH MILL AVE NW
CANAL FULTON OH
44614-9344
US

IV. Provider business mailing address

7055 HIGH MILL AVE NW
CANAL FULTON OH
44614-9344
US

V. Phone/Fax

Practice location:
  • Phone: 330-854-4545
  • Fax: 330-854-6319
Mailing address:
  • Phone: 330-854-4545
  • Fax: 330-854-6319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number001063N
License Number StateOH

VIII. Authorized Official

Name: MS. CORITA C CHILDS
Title or Position: PRESIDENT
Credential: LNHA
Phone: 330-854-4545