Healthcare Provider Details

I. General information

NPI: 1629060058
Provider Name (Legal Business Name): OTTERBEIN PORTAGE VALLEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20311 PEMBERVILLE RD
PEMBERVILLE OH
43450-9413
US

IV. Provider business mailing address

20311 PEMBERVILLE RD
PEMBERVILLE OH
43450-9413
US

V. Phone/Fax

Practice location:
  • Phone: 419-833-7000
  • Fax: 419-833-5763
Mailing address:
  • Phone: 419-833-7000
  • Fax: 419-833-5763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4762
License Number StateOH

VIII. Authorized Official

Name: MRS. RITA C HAWKINS
Title or Position: AVP FINANCE/CONTROLLER
Credential:
Phone: 513-933-5401