MEDICARE: LISBON SKILLED NURSING AND RESIDENTIAL CARE, 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

General Provider Information

NPI Number	:	1366816928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISBON SKILLED NURSING AND RESIDENTIAL CARE, LLC

Provider Business Mailing Address
First Line	:	7261 ENGLE RD
Second Line	:	STE 200
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-8467
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 VISTA DR
Second Line	:
City	:	LISBON
State	:	OH
Zip	:	44432-1008
Country	:	US
Telephone Number	:	216-772-1105
Fax Number	:

Authorized Official
Title or Position	:	GENERAL COUNSEL
Name	:	BENJAMIN PARSONS
Credential	:
Telephone Number	:	216-772-3192

Provider Enumeration Date	:	11/19/2015
Last Update Date	:	11/19/2015

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