MEDICARE: KETHLEY HOUSE @ BENJAMIN ROSE PLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	0675	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083600118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETHLEY HOUSE @ BENJAMIN ROSE PLACE

Provider Business Mailing Address
First Line	:	11900 FAIRHILL RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-1053
Country	:	US
Telephone Number	:	216-795-5450
Fax Number	:	216-795-1178

Provider Business Practice Location Address
First Line	:	11900 FAIRHILL RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-1053
Country	:	US
Telephone Number	:	216-795-5450
Fax Number	:	216-795-1178

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. MARY S. MARITA
Credential	:	L.N.H.A.
Telephone Number	:	216-373-1807

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	08/22/2020

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Directions to “KETHLEY HOUSE @ BENJAMIN ROSE PLACE ” Practice Location

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