Healthcare Provider Details

I. General information

NPI: 1689771826
Provider Name (Legal Business Name): CAPITAL SENIOR LIVING, ILM-B INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 22ND ST NW
CANTON OH
44708-1573
US

IV. Provider business mailing address

4515 22ND ST NW
CANTON OH
44708-1573
US

V. Phone/Fax

Practice location:
  • Phone: 330-477-7664
  • Fax: 330-478-9645
Mailing address:
  • Phone: 330-477-7664
  • Fax: 330-478-9645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5977
License Number StateOH

VIII. Authorized Official

Name: MS. KRISTEN JOY GASPER
Title or Position: ACCOUNTING DIRECTOR
Credential:
Phone: 330-477-7664