Healthcare Provider Details

I. General information

NPI: 1093877110
Provider Name (Legal Business Name): WHITEHOUSE OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11239 WATERVILLE ST
WHITEHOUSE OH
43571-9813
US

IV. Provider business mailing address

7400 NEW LA GRANGE RD SUITE 100
LOUISVILLE KY
40222-4870
US

V. Phone/Fax

Practice location:
  • Phone: 419-877-5338
  • Fax: 419-877-1049
Mailing address:
  • Phone: 502-429-8062
  • Fax: 502-429-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number6295
License Number StateOH

VIII. Authorized Official

Name: MR. STACEY PAUL ROGERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 502-429-8062