Healthcare Provider Details

I. General information

NPI: 1689964306
Provider Name (Legal Business Name): LOST CREEK CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 S MUMAUGH RD
LIMA OH
45804-3569
US

IV. Provider business mailing address

804 S MUMAUGH RD
LIMA OH
45804-3569
US

V. Phone/Fax

Practice location:
  • Phone: 567-712-7569
  • Fax:
Mailing address:
  • Phone: 567-712-7569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number005613
License Number StateOH

VIII. Authorized Official

Name: DIONNA NOONAN
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 614-563-4713