Healthcare Provider Details

I. General information

NPI: 1114152378
Provider Name (Legal Business Name): CARRIAGE COURT HILLIARD LESSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3570 HERITAGE CLUB DR
HILLIARD OH
43026-1372
US

IV. Provider business mailing address

78 CENTENNIAL LOOP
EUGENE OR
97401-7900
US

V. Phone/Fax

Practice location:
  • Phone: 614-529-7470
  • Fax: 614-529-7480
Mailing address:
  • Phone: 541-747-3373
  • Fax: 541-868-8447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: JOHN HOLTZ
Title or Position: CONTROLLER
Credential:
Phone: 541-747-3373