=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154409993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONACARE OF OHIO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 10/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 NORMANDY DR
-----------------------------------------------------
City | PAINESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-1616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-357-1311
-----------------------------------------------------
Fax | 440-357-1299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 S 4TH ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-596-7301
-----------------------------------------------------
Fax | 502-596-4134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY
-----------------------------------------------------
Name | MARILYN A. WEAVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-596-7563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 5868
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------