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	310400000X	Assisted Living Facility	2090R	OH
2	314000000X	Skilled Nursing Facility	2090N	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
2	000000321362	OTHER	OH	ANTHEM
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407843931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISBON SKILLED NURSING AND RESIDENTIAL CARE, LLC

Provider Business Mailing Address
First Line	:	2875 CENTER RD STE 6
Second Line	:
City	:	BRUNSWICK
State	:	OH
Zip	:	44212-2319
Country	:	US
Telephone Number	:	216-772-1105
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	:	330-424-5852
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	MR. BENJAMIN PARSONS
Credential	:
Telephone Number	:	216-772-1105

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	01/26/2023

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