Healthcare Provider Details

I. General information

NPI: 1073100681
Provider Name (Legal Business Name): THE LODGE ACTIVITY CENTER LLC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 EATON AVE
HAMILTON OH
45013-1407
US

IV. Provider business mailing address

654 HISTORY BRIDGE LN
HAMILTON OH
45013-3660
US

V. Phone/Fax

Practice location:
  • Phone: 513-291-0974
  • Fax:
Mailing address:
  • Phone: 513-291-0974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CELENA V PARKER
Title or Position: CEO
Credential:
Phone: 513-291-0974