=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609870138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZA JENNINGS HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 10/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10603 DETROIT AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44102-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-226-0282
-----------------------------------------------------
Fax | 216-226-8905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10603 DETROIT AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44102-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-226-0282
-----------------------------------------------------
Fax | 216-226-8905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. BASABI RATNAPARKHI
-----------------------------------------------------
Credential | LNHA
-----------------------------------------------------
Telephone | 216-226-0282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 4162
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------