Healthcare Provider Details

I. General information

NPI: 1104530682
Provider Name (Legal Business Name): CLINIC LEASING CO., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 CLINIC DR
IVYDALE WV
25113-8266
US

IV. Provider business mailing address

10123 ALLIANCE RD
BLUE ASH OH
45242-4887
US

V. Phone/Fax

Practice location:
  • Phone: 304-286-4204
  • Fax:
Mailing address:
  • Phone: 513-530-1808
  • 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: CHARLES STOLTZ
Title or Position: TREASURER
Credential:
Phone: 513-530-1808