Healthcare Provider Details

I. General information

NPI: 1558845750
Provider Name (Legal Business Name): WATERVILLE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8885 BROWNING DR
WATERVILLE OH
43566-9701
US

IV. Provider business mailing address

544 ENTERPRISE DR
LEWIS CENTER OH
43035-9704
US

V. Phone/Fax

Practice location:
  • Phone: 419-878-8523
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: PAUL BERGSTEN
Title or Position: MANAGER
Credential:
Phone: 937-825-6622