MEDICARE: ELYRIA LARGE GROUP HOMES, INC.

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	315P00000X	Intellectual Disabilities Intermediate Care Facility		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	:	1154516581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELYRIA LARGE GROUP HOMES, INC.

Provider Business Mailing Address
First Line	:	25000 COUNTRY CLUB BLVD
Second Line	:	STE 255
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-5344
Country	:	US
Telephone Number	:	440-614-0160
Fax Number	:	440-614-0168

Provider Business Practice Location Address
First Line	:	1251 EAST AVE
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-7674
Country	:	US
Telephone Number	:	440-322-0726
Fax Number	:	440-322-2810

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN COLLERAN
Credential	:
Telephone Number	:	440-614-0160

Provider Enumeration Date	:	09/10/2007
Last Update Date	:	08/06/2009

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