Healthcare Provider Details

I. General information

NPI: 1437757143
Provider Name (Legal Business Name): EXECUTIVE HERITAGE'S ASSISTED LIVING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 EXECUTIVE PARK DR STE 240
CINCINNATI OH
45241-2094
US

IV. Provider business mailing address

4050 EXECUTIVE PARK DR STE 240
CINCINNATI OH
45241-2094
US

V. Phone/Fax

Practice location:
  • Phone: 513-518-4631
  • Fax:
Mailing address:
  • Phone: 513-518-4631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMANUEL DANIACHEW
Title or Position: OWNER
Credential: MD
Phone: 619-403-6906