Healthcare Provider Details

I. General information

NPI: 1831987635
Provider Name (Legal Business Name): HALL OF FAME DIVINE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 13TH ST NW
CANTON OH
44708-3121
US

IV. Provider business mailing address

5915 LANDERBROOK DR STE 350
MAYFIELD HEIGHTS OH
44124-4063
US

V. Phone/Fax

Practice location:
  • Phone: 330-620-7828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY DEGYANSKY
Title or Position: VP OF OPERATIONS
Credential:
Phone: 330-620-7828