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General NPI Number Information
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NPI Number | 1891864823
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Entity Type | Organization
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Legal Business Name | SUPREME COUNCIL OF THE HOUSE OF JACOB OF THE USA INC
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 07/23/2009
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Provider Practice Location Address
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Address Line | 25680 TOWNSHIP RD. 39
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City | COSHOCTON
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State | OH
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Zip | 43812-9195
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Country | US
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Telephone | 740-824-3635
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Fax | 740-824-5205
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Provider Business Mailing Address
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Address Line | 25680 TOWNSHIP RD. 39
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City | COSHOCTON
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State | OH
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Zip | 43812-9195
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Country | US
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Telephone | 740-824-3635
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Fax | 740-824-5205
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | HULDAH M. CHESNUT
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Credential | NHA
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Telephone | 740-824-3635
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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 | 2436
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License Number State | OH
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