Healthcare Provider Details

I. General information

NPI: 1003939786
Provider Name (Legal Business Name): OTTERBEIN PERRYSBURG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3529 RIVERS EDGE DRIVE
PERRYSBURG OH
43551
US

IV. Provider business mailing address

580 N STATE ROUTE 741
LEBANON OH
45036-8839
US

V. Phone/Fax

Practice location:
  • Phone: 419-874-2428
  • Fax: 419-872-8464
Mailing address:
  • Phone: 513-932-5401
  • Fax: 513-932-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2480N
License Number StateOH

VIII. Authorized Official

Name: JAMES CHRIS GREEN
Title or Position: TREASURER & CFO
Credential: CPA
Phone: 513-933-5418