Healthcare Provider Details

I. General information

NPI: 1841689650
Provider Name (Legal Business Name): EMBASSY GARDEN COURT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 COVENANT HOUSE DR
DAYTON OH
45426-2007
US

IV. Provider business mailing address

544 ENTERPRISE DRIVE
LEWIS CENTER OH
43035
US

V. Phone/Fax

Practice location:
  • Phone: 937-837-2651
  • Fax: 937-837-5831
Mailing address:
  • Phone: 937-825-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1515N
License Number StateOH

VIII. Authorized Official

Name: PAUL B BERGSTEN
Title or Position: CEO
Credential:
Phone: 937-825-6622