MEDICARE: ELYRIA ICF II,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	315P00000X	Intellectual Disabilities Intermediate Care Facility		OH

General Provider Information

NPI Number	:	1457782591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELYRIA ICF II,LLC

Provider Business Mailing Address
First Line	:	9901 LINN STATION RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1271 EAST AVE
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-7674
Country	:	US
Telephone Number	:	440-322-0726
Fax Number	:

Authorized Official
Title or Position	:	PARALEGAL
Name	:	MS. MARY A PANK
Credential	:
Telephone Number	:	502-420-2666

Provider Enumeration Date	:	11/27/2013
Last Update Date	:	07/11/2016

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