Healthcare Provider Details

I. General information

NPI: 1538658489
Provider Name (Legal Business Name): FHS PINE GROVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 SHERMAN ST
GENEVA OH
44041-9101
US

IV. Provider business mailing address

25000 COUNTRY CLUB BLVD STE 255
NORTH OLMSTED OH
44070-5337
US

V. Phone/Fax

Practice location:
  • Phone: 440-415-0502
  • Fax: 440-415-0504
Mailing address:
  • Phone: 440-614-0160
  • Fax: 440-614-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1405N
License Number StateOH

VIII. Authorized Official

Name: BRIAN COLLERAN
Title or Position: PRESIDENT
Credential:
Phone: 440-343-2053