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General NPI Number Information
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NPI Number | 1598923575
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Entity Type | Organization
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Legal Business Name | VAN GORDER MANOR
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Dates
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Enumeration Date | 05/27/2008
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Last Update Date | 05/27/2008
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Provider Practice Location Address
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Address Line | 37819 EUCLID AVE
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City | WILLOUGHBY
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State | OH
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Zip | 44094-5900
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Country | US
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Telephone | 440-946-5213
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Fax | 440-942-0244
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Provider Business Mailing Address
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Address Line | 37819 EUCLID AVE
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City | WILLOUGHBY
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State | OH
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Zip | 44094-5900
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Country | US
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Telephone | 440-946-5213
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Fax | 440-942-0244
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MICHELLE LEE WAGNER
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Credential |
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Telephone | 440-946-5213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 1954
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License Number State | OH
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