Healthcare Provider Details

I. General information

NPI: 1043463821
Provider Name (Legal Business Name): PEREGRINE HEALTH SERVICES OF EDGERTON,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 W VINE ST
EDGERTON OH
43517-9600
US

IV. Provider business mailing address

328 W VINE ST
EDGERTON OH
43517-9600
US

V. Phone/Fax

Practice location:
  • Phone: 419-298-2321
  • Fax: 419-298-2476
Mailing address:
  • Phone: 419-298-2321
  • Fax: 419-298-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1410
License Number StateOH

VIII. Authorized Official

Name: OSCAR G ALEMAN
Title or Position: CONTROLLER
Credential:
Phone: 614-459-2482