Healthcare Provider Details

I. General information

NPI: 1063409522
Provider Name (Legal Business Name): 3102 SAINT CHARLES DRIVE OPERATING COMPANY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 SAINT CHARLES DR
STEUBENVILLE OH
43952-3508
US

IV. Provider business mailing address

3102 SAINT CHARLES DR
STEUBENVILLE OH
43952-3508
US

V. Phone/Fax

Practice location:
  • Phone: 740-264-7161
  • Fax: 740-264-7116
Mailing address:
  • Phone: 740-264-7161
  • Fax: 740-264-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1494N
License Number StateOH

VIII. Authorized Official

Name: MRS. JANA L SMITH
Title or Position: AR DIRECTOR
Credential:
Phone: 937-277-0505