Healthcare Provider Details

I. General information

NPI: 1295728905
Provider Name (Legal Business Name): LAUREL LAKE RETIREMENT COMMUNITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2005
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LAUREL LAKE DR
HUDSON OH
44236-2156
US

IV. Provider business mailing address

200 LAUREL LAKE DR
HUDSON OH
44236-2156
US

V. Phone/Fax

Practice location:
  • Phone: 330-655-1402
  • Fax: 330-655-1700
Mailing address:
  • Phone: 330-655-1402
  • Fax: 330-655-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4131
License Number StateOH

VIII. Authorized Official

Name: MRS. STEPHANIE COVAS
Title or Position: ADMINISTRATOR
Credential:
Phone: 330-655-1402