Healthcare Provider Details

I. General information

NPI: 1609957901
Provider Name (Legal Business Name): GREAT TRAIL CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CAROLYN CT
MINERVA OH
44657-8703
US

IV. Provider business mailing address

400 CAROLYN CT
MINERVA OH
44657-8703
US

V. Phone/Fax

Practice location:
  • Phone: 330-868-4104
  • Fax: 330-868-7714
Mailing address:
  • Phone: 330-868-4104
  • Fax: 330-868-7714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5935
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2007303
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: MS. MELISSA SCHMIDT
Title or Position: ADMINISTRATOR
Credential:
Phone: 330-868-4104