Healthcare Provider Details

I. General information

NPI: 1861196982
Provider Name (Legal Business Name): LEGACY CENTERVILLE OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E ALEX BELL RD
CENTERVILLE OH
45459-2637
US

IV. Provider business mailing address

12380 PLAZA DR
PARMA OH
44130-1043
US

V. Phone/Fax

Practice location:
  • Phone: 937-436-9700
  • Fax: 937-436-1495
Mailing address:
  • Phone: 216-898-8399
  • Fax: 216-898-8455

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: JIM TAYLOR
Title or Position: CEO
Credential:
Phone: 440-590-0969