Healthcare Provider Details

I. General information

NPI: 1205881661
Provider Name (Legal Business Name): THE LAURELS OF ROCKFORD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10731 STATE ROUTE 118
ROCKFORD OH
45882-8947
US

IV. Provider business mailing address

8181 WORTHINGTON RD
WESTERVILLE OH
43082-8067
US

V. Phone/Fax

Practice location:
  • Phone: 419-363-2620
  • Fax: 419-363-2354
Mailing address:
  • Phone: 614-794-8800
  • Fax: 614-794-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1492N
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1492N
License Number StateOH

VIII. Authorized Official

Name: MR. ANIS KHAN
Title or Position: CFO
Credential:
Phone: 614-794-8800