Healthcare Provider Details

I. General information

NPI: 1992977516
Provider Name (Legal Business Name): OTTERBEIN CLEARCREEK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 AVALON CIRCLE
CENTERVILLE OH
45458
US

IV. Provider business mailing address

580 N STATE ROUTE 741
LEBANON OH
45036-8839
US

V. Phone/Fax

Practice location:
  • Phone: 937-885-5426
  • Fax: 937-885-4969
Mailing address:
  • Phone: 513-933-5401
  • Fax: 513-932-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2518N
License Number StateOH

VIII. Authorized Official

Name: JAMES CHRIS GREEN
Title or Position: TREASURER & CFO
Credential: CPA
Phone: 513-933-5418