Healthcare Provider Details

I. General information

NPI: 1609089135
Provider Name (Legal Business Name): MELLON RIDGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1659 STATE ROUTE 28
GOSHEN OH
45122-9705
US

IV. Provider business mailing address

22021 BROOKPARK RD STE 123
FAIRVIEW PARK OH
44126-3100
US

V. Phone/Fax

Practice location:
  • Phone: 513-575-5052
  • Fax: 440-614-0168
Mailing address:
  • Phone: 440-614-0160
  • Fax: 440-614-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2036
License Number StateOH

VIII. Authorized Official

Name: BRIAN COLLERAN
Title or Position: PRESIDENT
Credential:
Phone: 440-614-0160