Healthcare Provider Details

I. General information

NPI: 1033100698
Provider Name (Legal Business Name): GRACE BRETHREN VILLAGE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 TAYWOOD RD
ENGLEWOOD OH
45322-2400
US

IV. Provider business mailing address

1010 TAYWOOD RD
ENGLEWOOD OH
45322-2400
US

V. Phone/Fax

Practice location:
  • Phone: 937-836-4011
  • Fax:
Mailing address:
  • Phone: 937-836-4011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2050
License Number StateOH

VIII. Authorized Official

Name: MR. MIKE JACKIE MONTGOMERY
Title or Position: ASSISTANT ADMINISTRATOR
Credential: LNHA
Phone: 937-836-4011