=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336483833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE INN AT COALRIDGE MANAGEMENT CO. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2012
-----------------------------------------------------
Last Update Date | 11/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 COALRIDGE
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-334-1546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 COALRIDGE
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-334-1546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | CHAD MCCABE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-334-1546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 2609R
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------