MEDICARE: AJ CANDLEWOOD PARK OPCO 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	1426N	OH

General Provider Information

NPI Number	:	1497259923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AJ CANDLEWOOD PARK OPCO LLC

Provider Business Mailing Address
First Line	:	555 ANTHONY WAYNE TRL
Second Line	:
City	:	WATERVILLE
State	:	OH
Zip	:	43566-1516
Country	:	US
Telephone Number	:	330-720-0406
Fax Number	:

Provider Business Practice Location Address
First Line	:	1835 BELMORE RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-4301
Country	:	US
Telephone Number	:	216-268-3600
Fax Number	:	216-761-1322

Authorized Official
Title or Position	:	ATTORNEY
Name	:	HAYLEY B WILLIAMS
Credential	:
Telephone Number	:	216-706-3936

Provider Enumeration Date	:	03/20/2018
Last Update Date	:	04/26/2018

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