Healthcare Provider Details

I. General information

NPI: 1801383666
Provider Name (Legal Business Name): CT OHIO XENIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 WILSON DR
XENIA OH
45385-1848
US

IV. Provider business mailing address

126 WILSON DR
XENIA OH
45385-1848
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-2121
  • Fax: 937-376-1457
Mailing address:
  • Phone: 937-376-2121
  • 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
Identifier141350
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: MR. RAFAEL A MOERMAN
Title or Position: MANAGER
Credential:
Phone: 516-865-1500