Healthcare Provider Details

I. General information

NPI: 1831216688
Provider Name (Legal Business Name): WHITEHOUSE COUNTRY MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11239 WATERVILLE ST
WHITEHOUSE OH
43571-9813
US

IV. Provider business mailing address

11239 WATERVILLE ST
WHITEHOUSE OH
43571-9813
US

V. Phone/Fax

Practice location:
  • Phone: 419-877-5338
  • Fax: 419-877-1049
Mailing address:
  • Phone: 419-877-5338
  • Fax: 419-877-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1698N
License Number StateOH

VIII. Authorized Official

Name: MS. DEBRA S TOWNSEND
Title or Position: ADMINISTRATOR
Credential:
Phone: 419-877-5338