Healthcare Provider Details

I. General information

NPI: 1912374083
Provider Name (Legal Business Name): EMBASSY LONGMEADOW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 BRYN MAWR ST
RAVENNA OH
44266-9696
US

IV. Provider business mailing address

24579 BROADWAY AVE
OAKWOOD VILLAGE OH
44146-6338
US

V. Phone/Fax

Practice location:
  • Phone: 330-297-5781
  • Fax: 330-297-6921
Mailing address:
  • Phone: 330-297-5781
  • Fax: 330-297-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1628N
License Number StateOH

VIII. Authorized Official

Name: HAYLEY B WILLIAMS
Title or Position: ATTORNEY
Credential:
Phone: 216-706-3936