Healthcare Provider Details

I. General information

NPI: 1891864823
Provider Name (Legal Business Name): SUPREME COUNCIL OF THE HOUSE OF JACOB OF THE USA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25680 TOWNSHIP RD. 39
COSHOCTON OH
43812-9195
US

IV. Provider business mailing address

25680 TOWNSHIP RD. 39
COSHOCTON OH
43812-9195
US

V. Phone/Fax

Practice location:
  • Phone: 740-824-3635
  • Fax: 740-824-5205
Mailing address:
  • Phone: 740-824-3635
  • Fax: 740-824-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2436
License Number StateOH

VIII. Authorized Official

Name: HULDAH M. CHESNUT
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 740-824-3635