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General NPI Number Information
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NPI Number | 1538658489
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Entity Type | Organization
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Legal Business Name | FHS PINE GROVE, INC.
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Dates
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Enumeration Date | 05/07/2018
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Last Update Date | 05/07/2018
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Provider Practice Location Address
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Address Line | 840 SHERMAN ST
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City | GENEVA
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State | OH
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Zip | 44041-9101
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Country | US
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Telephone | 440-415-0502
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Fax | 440-415-0504
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Provider Business Mailing Address
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Address Line | 25000 COUNTRY CLUB BLVD STE 255
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City | NORTH OLMSTED
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State | OH
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Zip | 44070-5337
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Country | US
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Telephone | 440-614-0160
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Fax | 440-614-0168
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN COLLERAN
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Credential |
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Telephone | 440-343-2053
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 1405N
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License Number State | OH
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