MEDICARE: BALTIC AVENUE ENTERPRISES, LLC

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	5631	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	:	1134116130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALTIC AVENUE ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	7451 PLEASANT VIEW DR
Second Line	:	P.O. BOX 472
City	:	LISBON
State	:	OH
Zip	:	44432-9462
Country	:	US
Telephone Number	:	330-424-3721
Fax Number	:	330-424-7426

Provider Business Practice Location Address
First Line	:	7451 PLEASANT VIEW DR
Second Line	:
City	:	LISBON
State	:	OH
Zip	:	44432-9462
Country	:	US
Telephone Number	:	330-424-3721
Fax Number	:	330-424-7426

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MR. TIMOTHY A CHESNEY
Credential	:
Telephone Number	:	330-424-3721

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	08/22/2020

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Directions to “BALTIC AVENUE ENTERPRISES, LLC ” Practice Location

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