Healthcare Provider Details

I. General information

NPI: 1194729038
Provider Name (Legal Business Name): WILLOW PARK CONVALESCENT HOME,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18810 HARVARD AVE
CLEVELAND OH
44122-6848
US

IV. Provider business mailing address

18810 HARVARD AVE
CLEVELAND OH
44122-6848
US

V. Phone/Fax

Practice location:
  • Phone: 216-752-3600
  • Fax: 216-752-5612
Mailing address:
  • Phone: 216-752-3600
  • Fax: 216-752-5612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4104
License Number StateOH

VIII. Authorized Official

Name: ADAM J WHITE
Title or Position: AR MANAGER
Credential: MBA
Phone: 614-416-2638