Healthcare Provider Details

I. General information

NPI: 1457391294
Provider Name (Legal Business Name): HEARTLAND OF WATERVILLE OH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8885 BROWNING DR
WATERVILLE OH
43566-9701
US

IV. Provider business mailing address

333 N SUMMIT ST
TOLEDO OH
43604-2615
US

V. Phone/Fax

Practice location:
  • Phone: 419-878-8523
  • Fax: 419-878-0818
Mailing address:
  • Phone: 419-252-5500
  • Fax: 877-385-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1787N
License Number StateOH

VIII. Authorized Official

Name: MR. MARTIN D ALLEN
Title or Position: DIRECTOR
Credential:
Phone: 419-252-5734