=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578519500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LAURELS OF CHARLOTTESVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 08/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 490 HILLSDALE DR
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22901-5731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-951-4200
-----------------------------------------------------
Fax | 434-951-4201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8181 WORTHINGTON RD
-----------------------------------------------------
City | WESTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43082-8067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-794-8800
-----------------------------------------------------
Fax | 614-794-8826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ANIS KHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-794-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH2754
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NH2754
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------