Healthcare Provider Details

I. General information

NPI: 1669899746
Provider Name (Legal Business Name): KSMS CLEARVIEW LANTERN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 CHAMPION AVE W
WARREN OH
44483-1312
US

IV. Provider business mailing address

596 CHAMPION AVE W
WARREN OH
44483-1312
US

V. Phone/Fax

Practice location:
  • Phone: 330-847-6800
  • Fax:
Mailing address:
  • Phone: 330-847-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2096R
License Number StateOH

VIII. Authorized Official

Name: MR. BRAD WOOD
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 317-280-8455