=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649587668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIETTA CONTINUING CARE COMMUNITY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2010
-----------------------------------------------------
Last Update Date | 09/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 TIMBERLINE DR
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-9238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-376-0535
-----------------------------------------------------
Fax | 740-376-0153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 TIMBERLINE DR
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-9238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-376-0535
-----------------------------------------------------
Fax | 740-376-0153
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DITECTOR
-----------------------------------------------------
Name | MR. KENNETH E STRONG JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 740-376-0535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 2224R
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------