Healthcare Provider Details

I. General information

NPI: 1154463412
Provider Name (Legal Business Name): BROADFIELD MANOR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7927 MIDDLE RIDGE RD
MADISON OH
44057-3023
US

IV. Provider business mailing address

7927 MIDDLE RIDGE RD
MADISON OH
44057-3023
US

V. Phone/Fax

Practice location:
  • Phone: 440-466-3702
  • Fax: 440-466-7287
Mailing address:
  • Phone: 440-466-3702
  • Fax: 440-466-7287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0268
License Number StateOH

VIII. Authorized Official

Name: MR. PAUL JURIS BARBINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 440-466-3702