Healthcare Provider Details

I. General information

NPI: 1760605000
Provider Name (Legal Business Name): NORTH SHORE RETIREMENT COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 E NORTHSHORE BLVD
LAKESIDE OH
43440-1337
US

IV. Provider business mailing address

9400 E NORTHSHORE BLVD
LAKESIDE OH
43440-1337
US

V. Phone/Fax

Practice location:
  • Phone: 419-798-8203
  • Fax: 419-798-4662
Mailing address:
  • Phone: 419-798-8203
  • Fax: 419-798-4662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNA
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2057N
License Number StateOH

VIII. Authorized Official

Name: JAMES CHRIS GREEN
Title or Position: TREASURER & CFO
Credential: CPA
Phone: 513-933-5418