Healthcare Provider Details

I. General information

NPI: 1457463556
Provider Name (Legal Business Name): 204 W. MAIN STREET OPERATING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W MAIN ST
NEW LONDON OH
44851-1070
US

IV. Provider business mailing address

204 W MAIN ST
NEW LONDON OH
44851-1070
US

V. Phone/Fax

Practice location:
  • Phone: 419-929-1563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN P BRESLIN
Title or Position: EXECUTIVE VICE PRESIDENT - CFO
Credential:
Phone: 201-242-4000