Healthcare Provider Details

I. General information

NPI: 1538544416
Provider Name (Legal Business Name): PRISTINE SENIOR LIVING OF XENIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 WILSON DR
XENIA OH
45385-1848
US

IV. Provider business mailing address

3301 W PURDUE AVE
MUNCIE IN
47304-6356
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-2121
  • Fax:
Mailing address:
  • Phone: 317-408-8491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2244879
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: MR. CHRISTOPHER T COOK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 317-408-8491