Healthcare Provider Details

I. General information

NPI: 1821106576
Provider Name (Legal Business Name): MEADOW WOOD CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 STEPHENS AVE
GEORGETOWN OH
45121-9509
US

IV. Provider business mailing address

61 STEPHENS AVE
GEORGETOWN OH
45121-9509
US

V. Phone/Fax

Practice location:
  • Phone: 937-378-3727
  • Fax: 937-378-3733
Mailing address:
  • Phone: 937-378-3727
  • Fax: 937-378-3733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3566
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2326245
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: JACK CROUT
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 937-378-3727